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Illinois officials are calling for a public health assessment in Cahokia Heights, an area hit hard by flooding over the course of several years.

Illinois is once again allowing new 'nuclear energy plants' to be built in the state.

A federal judge hears arguments Tuesday on a case challenging the 'Illinois Gun Ban Registry'.

Bestselling author and St. Louis native Scott Alexander Hess will discuss his latest novel with filmmaker Geoff Story at Spine Bookstore (1976 Arsenal Street) on December 18. Publisher Rebel Satori released A Season in Delhi as the first of its new Bijou Book collection — a numbered series of shorter works, novellas and novelettes.

In St. Louis and across the country, gun buybacks have been touted as a way to get firearms out of the hands of criminals and permanently destroyed. But in many cases, including gun buybacks sponsored by police in St. Louis, it turns out that’s not what happens.

The overturning of Roe vs Wade last year has created massive fallout, with abortion-rights advocates scrambling to react. Voters in states like Kansas, Michigan and most recently Ohio have resoundingly supported ballot initiatives to protect abortion rights in their constitutions. Similar initiatives are being pursued in Florida, Arizona and my home state of Missouri. However […]

The post Any abortion initiative on Missouri ballot must end political interference in medical care appeared first on Missouri Independent.

by Cezary Podkul

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

A bipartisan group of six U.S. representatives has introduced a bill that would prohibit insurers and their intermediaries from levying fees on doctors for paying them electronically. The legislation comes in the wake of a ProPublica investigation that detailed the toll of such fees, which add up to billions of dollars that could be spent on care but are instead funneled to insurers and payment processors.

The charges are akin to having an employer deduct 1.5% to 5% to provide a paycheck electronically if an employee prefers to receive a payment directly into their bank account rather than via a paper check. Yet that’s the choice many insurers are increasingly forcing on doctors.

“We don’t tolerate paying fees to receive direct deposit of a paycheck, likewise, doctors and patients should not be forced to pay predatory fees on electronic payments on essential health services,” the bill’s lead sponsor, Republican Rep. Greg Murphy of North Carolina, said in a statement announcing the legislation. Murphy’s bill would effectively force the Centers for Medicare & Medicaid Services, the federal government’s chief regulator on health care payments, to prohibit the fees.

As it happens, that would bring the giant agency back to its original position. CMS prohibited fees for electronic funds transfers until it was lobbied by a payment processor called Zelis. The agency changed its position in 2018, then went even further in 2022, explicitly stating that such fees are not prohibited. A spokesperson for CMS said the agency does not comment on proposed legislation. Zelis did not reply to a request for comment on Murphy’s bill, but the company previously told ProPublica that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.”

CMS’s about-face was detailed in copious internal records meticulously collected by a New York City urologist, Dr. Alex Shteynshlyuger, who has made it his mission to fight the costly fees. His crusade now appears to have found a sympathetic ear in Congress: Like Shteynshlyuger, Murphy is a urologist, and he co-chairs the House GOP Doctors Caucus. Three Democrats and two Republicans thus far have signed on as co-sponsors of his bill.

The proposed legislation has the backing of the American Medical Association, whose policymaking body voted last month to adopt a new resolution opposing “growing and excessive” fees on electronic funds transfer payments. Shteynshlyuger, who has spent six years trying to convince CMS to ban the fees, introduced a proposal at New York state’s medical society that then made its way to the AMA. He said of the new federal bill: “I’m happy that the legislators got involved.”

Administrators at small medical clinics are hoping the bill will bring them relief from the fees, which are “doing nothing for us but costing us money,” said Rebecca Hamilton, who manages an arthritis and rheumatology clinic in Wichita, Kansas.

Often, it’s independent clinics like Hamilton’s that suffer the most from such fees, since medical practices collect the vast majority of their revenues through EFT payments, according to the Medical Group Management Association. The winners are the recipients of the fees: large insurers and payment processors like Zelis.

One form of electronic fee is not addressed by Murphy’s bill: charges for use of so-called virtual credit cards, which Shteynshlyuger has also been campaigning against. Virtual credit cards are temporary card numbers that are typically used for one payment. Fees for VCC use run as high as 5% versus a typical 2.5% for other kinds of electronic payments.

ProPublica’s investigation showed how Matthew Albright, a lobbyist for Zelis, used a combination of cajoling, argument and the threat of litigation to get CMS to withdraw a 2017 notice prohibiting fees for electronic payment. CMS had posted the notice, which was based on a federal rule from 2000, on its website after hearing complaints from doctors. Internal CMS emails detailed how Albright repeatedly demanded that CMS withdraw and revise the notice, and when CMS ultimately refused, a law firm representing Zelis threatened to sue the agency. Within days, CMS removed the notice. It later stated that fees are allowed.

CMS previously told ProPublica that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.”

Albright, like CMS, has changed his public position on the fees. Before he joined Zelis, Albright worked for the federal agency, where he wrote the rules implementing electronic health care payments. Shortly after his time at CMS, at a 2015 conference for health care business managers in Las Vegas, Albright expressed unequivocal opposition to fees for electronic payments. When Albright outlined the agency’s rules, audio of the event shows, the mere mention of virtual credit cards prompted some members of the audience to cry, “Evil!” Albright asked if that sentiment was unanimous, prompting a wave of yeses.

Doctors Shouldn’t Have to Pay to Get Paid

Before he became an industry lobbyist, Matthew Albright expressed opposition to electronic payment fees at a conference in Las Vegas in 2015.

Laughter ensued, and Albright, who has a master’s degree in divinity, joked that he was preaching to the choir. His sermon? “What other industry does not get paid for the services they’re doing, and when they do get paid, they have to pay for getting paid? What other industry, right? It’s ridiculous!”

Reached by telephone for comment, Albright said, “I can’t speak to you.”

A new national security task force has initiated 250 prosecutions, mostly against Palestinian students. Detainees have been held in maximum security prisons for weeks.

Speaker Mike Johnson inserted a four-month extension of a warrantless spying program into the annual defense policy bill.

by Annie Waldman

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Vascular surgeon Dr. Caitlin Hicks recalls the first time, about a decade ago, that a patient came to her with a lower leg mottled with purple and starting to decay. She searched for a pulse in the damaged limb, but blood had stopped flowing into it.

The patient had previously undergone an invasive vascular procedure, using devices designed to clear out clogged arteries. But when Hicks questioned the patient about the symptoms that had led them to initially seek treatment, they seemed mild or nonexistent.

Then Hicks saw another similar patient, and then another. In some cases, the only solution was amputation.

Over time, she began to worry if the patients landing on her operating table were a harbinger of something more ominous: doctors performing lucrative procedures on patients who might not have needed them.

In clinic offices and outpatient surgical centers, doctors were inserting into leg arteries catheters affixed with lasers or blades to pulverize fatty deposits from vessel walls. The procedures, called atherectomies, carried risks — of infection or the errant nick from a blade — that were perhaps worth the gamble for patients who could lose their legs from poor circulation. But some of the patients Hicks was treating had not initially been that sick.

“A lot of them would tell you, ‘Well, the doctor said I had a blockage in my artery,’” she said, “but if you asked them about symptoms, they didn’t actually have any.”

So Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine, and a team of academic physicians decided to do what regulators and insurers had not. They began years of groundbreaking, peer-reviewed research that revealed that some doctors appeared to be overusing atherectomy procedures, performing them on high numbers of patients who may not have needed them.

They built on studies that showed aggressive, invasive treatments made far less sense for patients with milder symptoms, like leg pain while walking, which is often caused by clogged arteries obstructed with plaque. The majority of these patients are unlikely to develop severe vascular disease, and they can often be treated with less invasive therapies like medication and exercise. While most doctors follow best practices, many have continued to use aggressive interventions, ProPublica found, often warning patients that without them, they could lose their limbs. Instead, research has shown, the procedures may be associated with a higher risk of amputation.

Hicks and her fellow researchers didn’t publicly reveal the outlier doctors, but four years ago, they disclosed their names to the Centers for Medicare and Medicaid Services, encouraging the government insurers to examine their own data and crack down on abuse. They also sent a list to the Society for Vascular Surgery, where senior medical society members and leaders in the field believed the time had come for tighter standards.

And then Hicks and her colleagues waited. Surely their careful, methodical and confidential evidence would prompt change. Instead, what they got was an at-times scalding wave of blowback.

Today, atherectomies remain unchecked, not only because regulators and insurers haven’t done enough to rein them in, ProPublica’s reporting has found, but because doing them remains easy and profitable. Since 2013, the number of atherectomies has doubled and payments to doctors have nearly tripled, totaling about half a billion dollars annually as of 2021, according the most recent year of Medicare data. Physicians can charge Medicare tens of thousands of dollars for multiple procedures conducted in a single office visit.

And the government’s own data shows it continues to pay individual providers millions of dollars a year to perform the procedures, including on patients with only milder symptoms, with little pushback and few rules.

In response to questions, CMS told ProPublica that it examines its billing data for outliers, taking action when it identifies problems by denying claims, suspending payments or referring questionable providers to law enforcement.

But the story of Hicks and her colleagues illustrates the challenges of highlighting potentially dangerous practices and effecting change, especially when physicians’ livelihoods are at stake.

What the researchers hadn’t bargained on was a vocal contingent of doctors willing to fight for their freedom to perform the vascular procedures as they saw fit in their private practices. While not all were outliers, many spent years attacking the overuse studies and the researchers behind them and wielding influence to mute reforms.

Nowhere was this opposition more palpable than this past May, at the annual meeting for the Outpatient Endovascular and Interventional Society, a group of doctors who treat vascular disease outside of hospitals and often in their own private practices. Among glass cases in which atherectomy catheters gleamed like luxury jewelry, hundreds of doctors convened at Walt Disney World’s Coronado Springs resort to learn how to bolster their businesses.

In one presentation, Dr. Sandeep Rao, an interventional radiologist from El Paso, Texas, flicked through a presentation on vascular procedure metrics. “That clinic patient, how well are you in getting to them on the table? And eventually, once you get them on the table, how well you’re converting them into the codes that you can bill for them?” Rao asked the room. “All of a sudden, if that patient doesn’t show up, now again, and that patient just goes, ‘I don’t want any more procedures,’ now that’s maybe something that you may not be able to bill for. So when I have a patient captured and captive on my table, I try to maximize how much I’m able to get.”

(Rao later told ProPublica his comments were focused on patient safety: He wanted to do every procedure necessary at once so that a patient didn’t have to return for a second set of procedures, risking complications.)

Protecting their practices — both from regulators and critics — was a persistent theme. No physician was perhaps as bold as interventional radiologist Dr. Alex Dabrowiecki of Oregon, who provocatively brandished a slide listing the recent academic articles from Hicks on atherectomy overuse. Stamped at the top in bold letters was the word “Fratricide.”

“There are some academic institutions who find [office-based laboratories] a threat or find big issues with how we are practicing,” he said. (Dabrowiecki later shared with ProPublica that his slide was meant as “tongue-in-cheek.”)

One of Dr. Alex Dabrowiecki’s slides at the annual meeting for the Outpatient Endovascular and Interventional Society. He later said that his slide was meant as “tongue-in-cheek.” (Obtained by ProPublica)

Vascular surgeon Dr. Robert Tahara, who leads the society for outpatient physicians, told ProPublica in an email that his members feel attacked by the research on procedure overuse. “I and many others simply but vociferously take issue with the portrayal that [office-based laboratory] docs are only using atherectomy as a revenue tool,” he said, noting that the Medicare data, used by Hicks and others, has many limitations that “precludes the ability to draw any meaningful conclusions.” Tahara added that terminology used by Rao at the conference was “ill crafted, not well conveyed and does not reflect the OEIS thinking.”

Other private practice doctors have accused Hicks of weaponizing ivory tower research and have vilified her as an “atherectomy nazi.” Some physicians have critiqued the focus on more milder vascular disease, which can have a range of symptoms. Last August, after she published an opinion piece in MedPage Today, which showed that many of her critics are performing atherectomies in the majority of their cases, doctors called on the Society for Vascular Surgery to end her “reign of terror,” threatening a mass exodus if the group did not somehow stop her from continuing her research.

“She will destroy the Society if she is not reined in,” wrote vascular surgeon Dr. Patrick Ryan, founder of the Nashville Vascular and Vein Institute, in a private society discussion board post that was shared with ProPublica, adding that her “abuse of claims data” made private practice doctors a target for regulators. The society later took the post down, citing “personal attacks that were clear violations,” society officials told ProPublica.

“The only result of her work that I have seen is promoting disunion within the [society],” Ryan later told ProPublica in an email, “making me and perhaps others angry that the life and limb-saving work we do every day is being cast as a money grab.”

Ryan, Tahara, Rao and Dabrowiecki did not stand out in a ProPublica analysis of possible atherectomy overuse.

Hicks bristled at the hostility but said her critics misunderstand her motivations.

“I’m just trying to talk about doing the best care possible for patients,” she said. “I’m not trying to suggest that a technology or a practice pattern is evil.”

Outpatient clinics can be an effective place to treat patients and atherectomy procedures are useful in some cases, Hicks said, but she reiterated that some doctors “are doing way too many of these interventions and hastening the worsening of disease in many patients.”

Hicks during a surgery. “I’m just trying to talk about doing the best care possible for patients,” she said. “I’m not trying to suggest that a technology or a practice pattern is evil.” (Rosem Morton for ProPublica)

Taking researchers’ mounting concerns of possible patient harm into account, the Society for Vascular Surgery tasked a group in 2018 to develop “appropriate use criteria” to guide doctors on how to treat their patients; these standards are also often used by insurers and regulators to decide which procedures should be covered and which deserve greater scrutiny.

The group determined that patients with milder disease should first be treated with exercise therapy and that invasive procedures should be reserved for those with severe lifestyle-limiting symptoms. In some circumstances, the group concluded, invasive procedures were flat-out “inappropriate.”

But before the standards could be published, the group faced familiar pushback. Some society members attacked the use of the word “inappropriate” to describe some procedures conducted on patients, urging the society to soften the language of the criteria.

“I have no doubt that the publication of this document will result in a huge backlash,” an unnamed society member reportedly said during an internal feedback process. “It will reinforce the perception that the society is trying to rein in the poorly informed, unwashed masses in the community, and protect patients from profit driven surgeons doing unnecessary procedures on their unwitting victims.”

Nearly all 23 authors of the criteria — many of them veteran, highly respected surgeons — wrote to society leadership in February 2022 to defend their process and its terminology, according to an internal letter that was leaked to ProPublica.

“The primary reason to retain the terminology was that the panelists, in fact, felt very strongly that there were certain scenarios that should be deemed as inappropriate,” they wrote. “Simply changing the terms at this point from ‘inappropriate’ to ‘rarely appropriate’ would not only violate the scientific integrity of the project, but [would] also be disrespectful to the extensive work invested by the panelists.”

But two months later, when the society published the criteria, it removed the terms “appropriate” and “inappropriate,” saying that the words have “different and often highly charged social connotations in the 21st century.” They replaced them with the more convoluted jargon “benefit outweighs risk (B>R)” and “risk outweighs benefit (R>B).”

Dr. Joseph Mills, the current president of the Society for Vascular Surgery, insisted that the terminology change didn’t undermine the project’s integrity. “We didn’t change the methodology, we didn’t change the message, we still published it,” he said. Mills, who was one of the authors of the criteria, said he recognizes that overuse is an issue, and that the society would not stop Hicks from doing her research. “We don’t want her to stop doing her work,” he said. “Our true north is always patients first and always try to stick with the science when there is science. I think we’ve been pretty consistent with that.”

But several physicians, including some authors of the criteria, told ProPublica that they felt leadership had caved to the complaints of a vocal minority and made the criteria more vague.

Dr. Rita Redberg, the former chief editor of JAMA Internal Medicine and a cardiologist who has studied vascular disease standards, said such terminology changes can have implications for patient care. “It just leaves a lot more wiggle room and room for interpretation and confusion,” she said. “It’s important to be accurate and scientifically correct. Certainly those kinds of changes for non-evidence based reasons raise a lot of concern.”

Just last month, the European Society for Vascular Surgery published its own practice guidelines, recommending conservative care for most patients with milder symptoms. In contrast to guidance in the United States, it explicitly discouraged routine atherectomy use for patients with milder symptoms, citing the procedure’s “lack of superiority” compared with other treatments, in terms of efficacy and safety.

Some American medical leaders have begun to doubt whether their societies have the capacity to truly address the outliers in their ranks. After former Society for Vascular Surgery president Dr. Kim Hodgson used his platform to call out procedure overuse two years ago, he said in response he was removed from the leadership of a society quality improvement program and projects he had lobbied for to improve care, including an initiative to educate physicians on whether they are outliers, were modified or thwarted.

“I think they have kowtowed to the outliers,” he told ProPublica. “People don’t like to get screamed, hollered and yelled at so they often will appease that group.”

Mills, the current society president, said that Hodgson was not removed from the quality improvement program because of his stance on atherectomies, but because he had retired from practicing surgery and officials wanted a leader who could work more collaboratively with all perspectives. “It wasn’t done to cave in to certain subgroups,” Mills said.

The outlier education initiative that Hodgson lobbied for may still be implemented, said Ken Slaw, the society’s executive director, but so far the society has implemented more voluntary improvement programs. “We could try to make up something like a report card and send it to surgeons and say this is where you lie on the curve of use,” Mills said. “The problem with that is that it makes us a police force.”

Despite the pushback, Hodgson, like Hicks, has not backed down. Standing before dozens of physicians at a conference last month, Hodgson once again appealed to his colleagues that, in the absence of bold society and regulatory action, the onus of protecting patients fell on them all individually.

“We all know who these people are,” he told the doctors. “If you don’t want to be part of the problem, you need to also recognize that part of the problem is the silence.”

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

by Annie Waldman, ProPublica, with data analysis by Alma Trotter and Fred Trotter, CareSet

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

More than 6.5 million Americans have peripheral artery disease, a condition in which arteries are obstructed, restricting blood flow, most often in the legs. The first sign is often leg pain during activity, also known as claudication. While most treatments are safe, in recent years, experts have warned that some doctors may be subjecting patients to invasive procedures too early in their disease progression, needlessly exposing them to risks of complications, including amputation and even death.

Over the past year, ProPublica has investigated these vascular treatments, and we found some doctors are earning millions of dollars conducting a questionable number of procedures. For treatments in outpatient clinics, federal insurers, like Medicare, pay generous reimbursements to doctors, who can charge tens of thousands of dollars for procedures done in a single office visit.

Treatments include widening the arteries with stents and balloons and clearing plaque from vessel walls with a laser or bladed catheter, also known as an atherectomy. Despite minimal evidence to support the treatment’s benefits compared with less expensive alternatives, atherectomies have surged in recent years, researchers have found, with hundreds of outlier doctors performing the procedure in a majority of their patient cases.

ProPublica found that, from 2017 through 2021, about 200 doctors accounted for more than half of atherectomy procedures and Medicare payments, totaling nearly $1.5 billion, according to public federal data. Many of these physicians work in outpatient clinics.

To better understand how doctors are using the procedure, ProPublica sought to analyze Medicare data for patients who underwent atherectomy treatments, working with the data journalism team at CareSet, a health analytics group that exists to transform Medicare data into insights for better patient care.

For our analysis, we set out to understand how often doctors were performing atherectomy procedures for patients in the early stages of disease. We relied on Medicare fee-for-service claims data and examined atherectomy procedures conducted over the past four years, from 2019 through 2022, limiting our analysis to the first-time atherectomy procedures that patients underwent during this time. We focused on initial atherectomy procedures to better understand whether interventions were occuring in the early stages of vascular disease, before possible progression of the illness. For each doctor, we calculated what percentage of their patients receiving a first-time atherectomy appeared to have had only more mild vascular disease, based on a diagnosis of claudication.

What Data Was Used for the Analysis?

When a patient is treated by a physician, medical details on their diagnoses and procedures are submitted to insurers for reimbursement payments. The Centers for Medicare and Medicaid Services collect this data for patients covered by its federal insurance and share it with the public and researchers, removing names and other private information to protect patient privacy.

To examine doctor reimbursement for atherectomy procedures, ProPublica relied on Medicare’s provider use and payment dataset, which contains details on the services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. This public data let us calculate how much Medicare paid each provider in reimbursement per type of procedure. We looked at five years of data, from 2017 through 2021, the most recent year available.

But the public reimbursement data does not include detailed information on provider behavior or patient diagnosis, so ProPublica partnered with CareSet, which has special access to Medicare claims data. The data included carrier, institutional inpatient and institutional outpatient claims. We used codes from the Current Procedural Terminology system, devised by the American Medical Association and used by Medicare, and we identified patients who underwent a first-time atherectomy procedure. We limited our analysis to patients who had procedures from Jan. 1, 2019, through Dec. 31, 2022.

We classified patients into two categories: those with more severe chronic disease, who had a diagnosis of chronic limb-threatening ischemia; and those who appeared to have milder vascular disease, based on a diagnosis of claudication. Patients with claudication were defined by the International Classification of Diseases code families I70.20, I70.21 and I73.9, a set of diagnosis codes used by other researchers in peer-reviewed studies. We omitted patients who underwent an atherectomy procedure before their first treatment in our study period. To do this, we looked back at the data 12 months before the start of our study period. We also excluded patients with a diagnosis of acute limb ischemia, which is often linked to an emergency event. We included patients who initially had a claudication diagnosis at the time of their first atherectomy procedure but whose disease may have advanced to a more severe stage during our study period, because of concerns that the interventions may have contributed to disease progression.

We pooled the patient-level data by doctor to calculate what percentage of each physician’s patients underwent a first-time atherectomy for claudication versus chronic limb-threatening ischemia.

Why Did We Focus on Patients With Claudication?

We wanted to know whether doctors who conduct atherectomies are using the procedure excessively on patients who appear to have milder vascular disease.

For many patients with peripheral artery disease, an initial symptom is pain when walking or exercising, which is also known as intermittent claudication. The discomfort often arises from limited oxygen in the leg muscles due to the narrowing of arteries, which can progressively become obstructed with plaque. According to experts, the majority of patients who experience claudication will not develop severe vascular disease, like chronic limb-threatening ischemia. While endovascular interventions are recognized by experts as appropriate for severe disease, best practices recommend that milder symptoms initially be managed by noninvasive care, which can slow or even reverse symptoms. These treatments may include exercise, diet changes, quitting smoking and medication.

The medical guidelines of several professional societies encourage starting with these noninvasive approaches. Last year, the Society for Vascular Surgery published appropriate use criteria for patients with claudication and recommended first-line treatments of exercise before resorting to interventions. It also advised against conducting procedures on arteries below the knee, emphasizing that interventions in these vessels for patients with claudication are of “unclear benefit and could be harmful.”

Just last month, the European Society for Vascular Surgery published its clinical practice guidelines on treating patients with asymptomatic peripheral artery disease and intermittent claudication, recommending conservative care for most of these patients. It also explicitly discouraged the routine use of atherectomy for patients with disabling claudication “due to the lack of superiority of atherectomy over conventional endovascular therapies in terms of efficacy and safety endpoints.”

Numerous studies have questioned the efficacy of atherectomy over the years, including from Cochrane, a widely respected network of experts that conducts systematic reviews of research. A Cochrane review found atherectomies are not necessarily more effective than alternative procedures. The studies on the effectiveness of atherectomy, it found, were small and had inconsistent results, and their methodologies had a “high risk of bias.”

While most doctors follow best practices, ProPublica has found that some opt for overly aggressive invasive treatments in early stages of vascular disease, which research has found may be associated with an increased risk of complications. In response to recent research, interviews with doctors and patients, and the recent medical guidelines and criteria, we sought to better understand doctor behavior in treating patients with claudication.

How Did We Develop Our Methodology?

Over the past year, our reporting has relied on numerous interviews with researchers, doctors and medical experts from various specialties, including but not limited to vascular surgery, interventional radiology and interventional cardiology. These conversations with experts have helped inform our analysis process. We also used several studies as a starting point for our own methodology, including some from Dr. Caitlin Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine and a leading researcher on procedure overuse.

One of the principal studies we relied on was “Use of Atherectomy during Index Peripheral Vascular Interventions,” which examined first-time vascular procedures, comparing atherectomies with other endovascular interventions, such as angioplasty and stenting. The researchers found substantial variation in how doctors use atherectomies as first-time procedures, with some using the treatment sparingly and others deploying it in a majority of their cases. High rates of atherectomy were more strongly associated with patients who had claudication and for procedures conducted in outpatient settings.

Another study that informed our process was “Overuse of early peripheral vascular interventions for claudication,” which sought to understand whether physicians were adhering to best practices for treating claudication, which recommend noninvasive approaches for patients in the early stages of the disease. Most doctors follow the practice guidelines, but researchers found a group of outlier physicians with high rates of intervention in patients newly diagnosed with claudication. Doctors who worked in high-volume outpatient settings also tended to have a higher rate of early intervention, which “supports the concern that some procedures for claudication may be overused for financial gain,” the authors concluded.

We also were informed by “Practice Patterns of Vascular Surgery’s ‘1%,’” which examined the use of procedures by vascular surgeons who accounted for the top 1% of all Medicare payments. The analysis found that of the $589 million in Medicare payments that went to vascular surgeons in 2016, the top 1% of that workforce — 31 doctors — received $91 million, or 15% of all payments. These outliers also accounted for 49% of the atherectomy payments to vascular surgeons. “The dramatic differences in practice patterns raise concern for potential overuse of specific, highly reimbursed services,” the researchers wrote.

While these studies, and several others, helped inform our process, our analysis with CareSet was independently conducted and did not rely on data of other researchers. Compared with the other studies, our analysis looked at a longer time frame, four years of data, and examined a different metric, percentage of a physician’s patients with claudication at the point of their initial atherectomy procedure.

What Are Our Top-Line Findings?

Relying on public Medicare data, we found that a small fraction of physicians conducting atherectomies account for a majority of the nation’s procedures and Medicare reimbursement payments. About 200 doctors were responsible for conducting nearly 200,000 atherectomies over five years.

Even though these providers only make up about a tenth of all doctors conducting the procedure, they accounted for 53% of all atherectomies in the country. Over five years, they received nearly $1.5 billion in reimbursements for them, representing almost two-thirds of all Medicare payments for the procedures. These physicians may be conducting more procedures and receiving more payments from commercial insurance and Medicaid, as our analysis only looked at Medicare data.

At the top of the list are three physicians from the greater Los Angeles area: Dr. Amiel Moshfegh with $45.8 million in Medicare reimbursement, Dr. Harold Tabaie with $24.8 million and Dr. Malwinder Singha with $23.8 million.

Doctors With Highest Medicare Reimbursement for Atherectomies From 2017 to 2021 Note: We defined an atherectomy procedure with Current Procedural Terminology codes 37225, 37227, 37229, 37231, 37233 and 37235. For each year of data, if a provider had fewer than 11 patients, they were not included in the dataset.

Relying on more detailed Medicare fee-for-service claims data analysis provided by CareSet, we calculated the number of patients who underwent a first-time atherectomy procedure during our study period when they appeared to have only had milder vascular disease based on a diagnosis of claudication.

Between 2019 through 2022, our analysis found that there were at least 121,000 patients who had first-time atherectomy procedures. Nearly 30,000 of these patients appeared to have more mild vascular disease, based on a diagnosis of claudication, according to the data, amounting to about 24.5%, or nearly 1 in 4 patients.

For about 170 doctors, half or more of their first-time atherectomy patients had only claudication as a diagnosis. And for nearly 780 doctors, a quarter or more of their first-time atherectomy patients had only claudication as a diagnosis. For more than 5,000 doctors, the number of claudication patients that had an atherectomy was too low to be reported, with fewer than 11 patients over four years.

Among high users of atherectomy, who conducted 200 or more procedures over four years, on average, about 15% of their patients appeared to have had more mild vascular disease based on a diagnosis of claudication.

Doctors Who Treated Most First-Time Atherectomy Patients With Milder Vascular Disease From 2019 to 2022 Note: We defined milder vascular disease based on a diagnosis of claudication at the time of the initial atherectomy procedure within our study period. Doctors Who Treated Largest Percentage of First-Time Atherectomy Patients With Milder Vascular Disease From 2019 to 2022 Note: We excluded physicians who conducted first-time atherectomies on fewer than 50 patients on average per year to focus on practitioners who have a higher use of the procedure over time. We defined milder vascular disease based on a diagnosis of claudication at the time of the initial atherectomy procedure within our study period.

While the data enables us to identify doctors that appear to have outlier treatment patterns, it does not allow us to determine the precise clinical reason why the doctors differ from peers or their motivation for conducting more procedures than other physicians. But researchers and experts told ProPublica that given the financial incentives to conduct atherectomy procedures in outpatient facilities, these patterns should raise alarms.

What Are the Limitations of Our Analysis?

Our analysis has some limitations. It relied on Medicare fee-for-service claims data, which is submitted by providers for financial purposes. While the data is supposed to be accurate, we cannot account for errors or inaccuracies — in particular, related to procedure or diagnosis codes — in what providers submit to Medicare. Despite the fact that electronic health record data is a richer resource, we did not use it as it’s not available at the scale required to conduct this study.

Medicare claims data only covers beneficiaries of the federal insurance program, and therefore we cannot make direct conclusions about beneficiaries with other insurance coverage. For patients with other insurance coverage, treatment patterns may look different. That said, it is estimated that more than 98% of American adults over the age of 65 are enrolled in Medicare, and about half of them appear in the fee-for-service data, which makes it one of the largest pools of health care information in the world.

Because Medicare claims data was submitted for billing purposes, it does not have complete clinical information on patient symptoms or disease severity. We do not have detailed information about arterial lesions, such as their exact locations, size or degree of occlusion, or clinical imaging, both of which might factor into a patient’s treatment plan. We also do not always know whether medication, exercise therapy or other less-invasive treatments were attempted before an invasive procedure, and if so, for how long. These kinds of programs are often not covered or tracked as part of the financial transaction.

Dr. Robert Tahara, president of the Outpatient Endovascular and Interventional Society, which represents doctors who treat vascular disease outside of hospitals and often in their own private practices, said Medicare’s claims data is not detailed enough to draw conclusions about doctor behavior. Tahara, who was not an outlier in our data, said that the data does not provide information on the stage of patients' disease, their disease progression or whether medical therapy didn’t work for them — details that could provide a greater understanding of why a treatment was chosen. “For example, the patient’s claudication could be worsening and coming close to critical limb ischemia, but the claim could still include a code for intermittent claudication,” he wrote in an email.

We relied on a 12-month lookback to determine whether the atherectomy was a first-time procedure. If a patient received an atherectomy before 2018, it is possible that we have identified a follow-up procedure rather than their first-time intervention. However, this should not impact our findings of whether they received an atherectomy when their recent diagnosis was for claudication.

As part of the data use agreement, we are unable to display data for doctors with fewer than 11 patients because of privacy concerns.

How Did Doctors React to Our Data Analysis?

Several experts and doctors called our findings concerning. Dr. Marty Makary, a professor of surgery and health care quality researcher at Johns Hopkins University School of Medicine, has used similar Medicare claims data to research outlier practice patterns and said that our analysis reinforces his own findings. “It is validating concerns on the grounds that some physicians are responding to a perverse financial incentive,” he said. “The data suggest they may be doing procedures on people who don’t need them.”

Makary leads Global Appropriateness Measures, a consortium of physicians who use clinical wisdom and health care data to detect outlier patterns and discourage overuse. Outlier analyses are critical for improving health care, he said, as most physicians change the way they practice when they learn that they stand out. “Our general principle is that 83% of outliers reduce their pattern of overuse after they see where they stand on the bell curve,” he said.

But several private practice doctors, including some of the outlier physicians we identified in our analysis, rebuffed our analysis or took issue with the use of Medicare claims data.

ProPublica reached out to every doctor named in our story through multiple emails and phone calls, providing questions to the physicians, their clinics, hospitals or lawyers. The following doctors, their offices or lawyers did not respond to ProPublica’s questions for this story at the time of publication: David Burkart, Ian Cawich, Thomas P. Davis, Pablo Guala, Omar Haqqani, Syed Hussain, Juan Kurdi, Moinakhtar Lala, James McGuckin, Jim Melton, Rajiv Nagesetty, Daniel Simon, Pushpinder Sivia and Harold Tabaie. Dr. Bhaskar Purushottam and Monument Health, where he works, both declined to comment. Riverside Healthcare in Illinois, where Hussain has worked since September 2022, declined to comment on the doctor’s practice. Kurdi’s lawyer declined to comment.

Florida vascular surgeon Dr. Joseph Ricotta, the national medical director of vascular surgery and endovascular therapy at Tenet Healthcare, said he rarely intervenes on patients with claudication, unless they have severe lesions. “The overwhelming majority of claudicants obviously we don’t intervene on,” he said. “The majority are managed with medical therapy.” Medicare claims data does not provide detail on the severity of arterial lesions, he said.

Maryland vascular surgeon Dr. Samer Saiedy, who was an outlier in the data, echoed these concerns and said the data doesn’t include enough details to provide a full picture of why he may have treated a patient with an invasive procedure. At his practice, patients are only given the option of invasive procedures, he said, if they have severe pain and have already tried less aggressive approaches first.

“If you look at atherectomy only, and you narrow down, yes, I’ll be an outlier because I do a lot of claudicants for severe symptoms after we do the medical treatment,” he said. “They cannot walk through the pain, they’re already on blood thinners, they’re already on this and already on this. We’re going to do something.”

Tennessee physician Dr. Prateek Gupta also took issue with our analysis, which he called “incomplete,” stating in an email that he is not “an outlier when you analyze all of the necessary factors.” Our analysis, he said, attempts “to allege medically unnecessary treatment based upon one factor” and that “a professional medical opinion about medical necessity is based upon multiple factors, indicia of disease, prognosis, anticipated patient outcome, alternative treatment options, patient preference and others.” Claudication can sometimes be debilitating for patients, he said. “As a practice with protocols, we manage most claudicants conservatively with medical therapy,” he said. “Patients with severe claudication get offered endovascular or open surgical procedures based on their comorbidities and preference if medical therapy fails.”

Jessica Johnson, the chief operating officer of South Dakota’s Vascular & Interventional Specialists, where Dr. Chad Laurich works, did not respond to specific questions regarding ProPublica’s analysis but said that the vascular surgeon had an “unwavering dedication to advancing vascular surgery while prioritizing patient well-being.” The community has “experienced improved wound healing, saved limbs, improved quality of life and many lives saved,” she said. Laurich did not directly respond to ProPublica’s questions.

Cherlynn Hecker, the clinical director at Dr. Christopher LeCroy’s practice, said that he doesn’t conduct procedures on patients with mild disease unless they have lifestyle limiting pain and have already tried exercise and medication therapy first. “This endovascular work is preventing patients having bypasses or amputation,” she said. LeCroy did not directly respond to ProPublica’s emailed questions.

Some doctors said billing errors explained their high rates of intervention on claudication patients. Dr. Colbert Perez said that his practice, Caprock Cardiovascular Center & Cath Lab in Lubbock, Texas, had been marking their patients with incorrect diagnosis codes in Medicare billing claims for several years, which made its patient population appear to have milder disease. Perez said that he rarely intervenes on patients with mild disease and that his practice, which outsources its coding and billing to another company, was looking into the billing issue and was in contact with CMS for corrections and changes. Billing errors can occur, but CMS mandates that physicians “are responsible for ensuring that claims submitted” under their name are “true and correct.”

Some physicians said that Medicare reimbursement data is misleading. Saiedy, who has made about $23.5 million from Medicare in reimbursements for atherectomy procedures over five years, according to federal data, said the payments cover all clinic expenses and are not going to him directly. “You have to look at the overhead of the practice,” he said. “That includes nurses, anesthesia, leases for the equipment, rent.”

California interventional radiologist, Dr. Malwinder Singha, who received $23.8 million in Medicare reimbursements for atherectomy procedures over five years according to federal data, echoed Saiedy’s concerns. “It is devoted to running of the [office-based laboratory] and only a tiny fraction is earned by the operator,” he wrote in an email to ProPublica. “I have to pay my employees and expenses for all the supplies (wires, balloons, stents, atherectomy catheters, etc.), imaging equipment, [electronic medical records], facilities rent, etc.”

Singha also took issue with the use of claims data to identify clinical outliers. “It does not take into account the patient population I see and the severity of their disease,” he said. He added that outpatient facilities are safe, and their patients are satisfied with their care. “What I and my colleagues do is safe and effective,” he said. “There are hundreds of office-based labs who treat thousands and thousands of patients. The adverse event rate is minuscule.”

Dr. Amiel Moshfegh, who received over $45 million in Medicare reimbursements for atherectomy procedures over five years according to Medicare data — more than any other doctor in the country — said his atherectomy statistics reflect “the quality outcomes generated for patients and the confidence of referral sources in directing patients” to his practice. He did not answer ProPublica’s questions on his treatment of patients with claudication.

Interventional radiologist Dr. James McGuckin, who received $17.2 million in Medicare reimbursements for atherectomy procedures over five years according to Medicare data, treats “a significantly high-risk patient base” who are at-risk for amputation, said his attorney, David Heim in an email this past August.

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

by Annie Waldman, ProPublica, with data analysis by Alma Trotter and Fred Trotter, CareSet

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Four years ago, researchers warned the Centers for Medicare and Medicaid Services that some doctors were overusing — potentially even abusing — invasive vascular procedures, increasing patients’ chances of complications, which include amputation or even death.

They handed the federal agency a list of outlier physicians they found in the government insurer’s own data. But the agency has done little to stop the practice and instead continues to pay doctors who exhibit this behavior millions of dollars a year.

The names of the doctors were never publicly revealed.

ProPublica is shedding new light on the problem.

Working with data journalists from the health analytics group CareSet, and in consultation with experts, ProPublica sought to better understand how often physicians were using one particularly controversial procedure, the atherectomy, on patients with questionable need for it. Over the past year, ProPublica has chronicled the rise of these procedures along with horror stories of patients who lost their legs from complications.

Their cases and many others, plus dozens of interviews with patients, health care providers and medical device representatives, have laid bare a thriving industry of strip-mall clinics and outpatient vascular centers where elderly patients are being exploited for multimillion-dollar Medicare payouts.

As part of the procedure, doctors use a laser or bladed catheter to remove plaque from the patients’ vessel walls. For treatments conducted in outpatient clinics, Medicare pays generous reimbursements to doctors, who can charge tens of thousands of dollars for procedures done in a single visit. Experts recognize atherectomies are appropriate for severe vascular disease, but they told ProPublica that the majority of patients with milder symptoms like leg pain while walking, a condition known as claudication, should start with treatments like medication and exercise.

We analyzed Medicare claims records for people who had first-time atherectomies between 2019 and 2022 and found that nearly 1 in 4 patients underwent the invasive procedure after only a diagnosis for claudication, indicating an early stage of vascular disease.

This amounts to nearly 30,000 patients who may have undergone procedures too soon or possibly even unnecessarily. (Read more about our findings and methodology.)

Some doctors stood out because of the money they made. Dr. Amiel Moshfegh, a Beverly Hills radiologist, received $45 million from Medicare over five years for performing thousands of atherectomies, according to public Medicare records. Most of his Medicare patients were older Latinos, according to federal data, who were warned in Spanish-language advertisements that poor circulation could lead to amputation. About 15% of his patients who underwent a first-time atherectomy, 170 of them, appeared to have milder disease based on their diagnosis for claudication, according to the data.

Other doctors stood out because a large portion of their patients who underwent atherectomies had just claudication, raising questions about the necessity of the procedures. That was the case for Dr. Christopher LeCroy, who works for a chain of vascular clinics across the Florida panhandle; about half of his first-time atherectomy patients appeared to have milder disease based on their diagnosis, according to the data.

And while over 5,000 physicians who provide vascular care rarely intervened on patients who appeared to have milder vascular disease based on their diagnoses, ProPublica and CareSet found that about 170 other doctors performed half or more of their first-time atherectomies on these kinds of patients.

“It’s concerning that we may be doing unnecessary procedures and spending unnecessary health care dollars,” said Dr. Caitlin Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine and a leading researcher on procedure overuse. “We know that aggressive interventions for claudication may give short-term relief, but in the long term, patients are the same as they started or even worse.”

Doctors named in our data objected to being portrayed as part of the problem.

Moshfegh, for example, noted he had no malpractice claims or blemishes on his license. “Atherectomies ultimately can save the government and taxpayers millions of dollars by avoiding amputations,” he said. He did not respond to ProPublica’s questions on his clinic’s use of advertisements, the treatment of patients with milder vascular disease or why he had received more Medicare reimbursements for atherectomy than any other physician in the country. (Read his full statement here.)

LeCroy did not directly respond to ProPublica’s questions sent by email, but the clinical director at his practice said he doesn’t conduct procedures on patients with mild disease unless they have lifestyle-limiting pain and have already tried exercise and medication therapy. “This endovascular work is preventing patients having bypasses or amputation,” said Cherlynn Hecker. Others echoed these points.

Several portrayed the mounting concerns about overuse as part of a debate, not settled science, and said they should be trusted to decide whether their patients can benefit from atherectomies. Private practice doctors also explained that their high reimbursement payments are meant to cover their total business expenses and do not lead to excessive personal profit. Some rebuffed ProPublica’s analysis, taking issue with the use of claims data, which they said does not provide key details on patient symptoms and critiquing the focus on claudication, which they said can have a range of severity. While Medicare claims data has limitations, academics across the country and even government fraud detectives use it to examine trends and identify outliers.

Johns Hopkins surgeon and researcher Dr. Marty Makary said these kinds of outlier analyses are crucial to protecting patients. “Most of the public is flying blind,” said Makary, who also leads the organization Global Appropriateness Measures, which uses similar medical data to address outliers and curb overuse. “The moral dilemma that the medical community is now facing is that we can see practice patterns in big data that are inappropriate. Do we have a duty to act? I think we do.”

Using the research of Hicks, Makary and their colleagues as a springboard, ProPublica has spent the past year examining Medicare data for vascular care to answer some basic questions: Which doctors are making the most money off a single procedure? Who are they treating? And what is happening to their patients?

Relying on public Medicare data, we found that about 200 doctors are responsible for a majority of atherectomies conducted across the country. Over five years, from 2017 through 2021, this small cadre of mostly vascular surgeons, interventional radiologists and cardiologists has earned nearly $1.5 billion dollars, conducting almost 200,000 procedures. At the top of the list sits Moshfegh, the Beverly Hills radiologist who raked in almost double the reimbursements of any other doctor in America, for over 7,000 atherectomy procedures.

Doctors With Highest Medicare Reimbursement for Atherectomies From 2017 to 2021 Note: We defined an atherectomy procedure with Current Procedural Terminology codes 37225, 37227, 37229, 37231, 37233 and 37235. For each year of data, if a provider had fewer than 11 patients, they were not included in the dataset.

While some vascular specialists making millions have developed national empires of clinics, been profiled on local television or garnered dozens of online patient reviews, Moshfegh has kept a remarkably low profile.

After completing his medical training in 2014, Moshfegh went into outpatient vascular care. For a couple years, he led endovascular services for the Los Angeles office of Vascular Access Centers, a national chain of clinics founded by Dr. James McGuckin.

Moshfegh later began working with FIT Vascular, a smaller vascular clinic chain with offices in central Los Angeles and Bakersfield, California. He appears to have worked closely with several podiatrists, sharing hundreds of patients primarily with two podiatry clinics, according to recent Medicare referral claims data from CareSet. One of the podiatry groups, Stockdale Podiatry in Bakersfield, also shares office space with FIT Vascular — the vascular suite sits behind a beige, unmarked door off of the podiatry clinic’s waiting room.

When a ProPublica reporter visited the clinic, Victoria Arredondo, a medical assistant for FIT Vascular, told ProPublica that Moshfegh travels to Bakersfield from Los Angeles several times a week to conduct artery procedures, treating half a dozen patients a day. Nearly all of their patient referrals came from Stockdale Podiatry, she said. While Moshfegh’s name is not listed on FIT Vascular’s website, he is featured in its marketing videos and his face appears in its advertisements.

The federal government generally forbids doctors from making payments to induce referrals or making referrals to entities they have a financial interest in. While it’s not prohibited for physicians to pay another doctor to lease office space, such real estate transactions must be consistent with fair market value to abide by federal law. Neither Stockdale Podiatry or FIT Vascular responded to ProPublica’s emailed questions, including those related to their real estate arrangement. Moshfegh did not respond to ProPublica’s questions about his relationship with the podiatry clinic, though he did say that he adheres “the highest standards of medical ethics” and that his atherectomy statistics reflect “the confidence of referral sources in directing patients” to his practice.

While the raw numbers can highlight doctors like Moshfegh who stand out for how many atherectomies they do, they don’t provide much detail on how individual patients are being treated. So ProPublica worked with CareSet to look at the types of patients that doctors treat, examining whether doctors were frequently conducting procedures on patients who appeared to have more mild disease based on their diagnoses. Using Medicare claims data, we identified patients who underwent a first-time atherectomy procedure between 2019 and 2022, and for each doctor, we calculated the percentage of these patients who only had claudication.

Doctors Who Treated Largest Percentage of First-Time Atherectomy Patients With Milder Vascular Disease From 2019 to 2022 Note: We excluded physicians who conducted first-time atherectomies on fewer than 50 patients on average per year to focus on practitioners who have a higher use of the procedure over time. We defined milder vascular disease based on a diagnosis of claudication at the time of the initial atherectomy procedure within our study period.

This highlighted doctors like Dr. Juan Kurdi of Lubbock, Texas; nearly half of his first-time atherectomy patients appeared to have milder disease based on their diagnosis, according to the data. Kurdi did not directly respond to ProPublica’s emailed questions or phone messages, and his lawyer declined to comment. Kurdi’s currently the target of a criminal investigation by the Department of Justice, according to court filings; he has not been charged. The government and his lawyers are discussing a potential pre-indictment resolution, according to case filings.

His colleague Dr. Colbert Perez, who was also high on this list with 37% of his first-time atherectomy patients having only claudication according to the data, said that their practice, Caprock Cardiovascular Center & Cath Lab, had been marking their patients with incorrect diagnosis codes in Medicare billing claims for several years, which made their patient population appear to have milder disease. While billing errors can occur, CMS mandates that physicians “are responsible for ensuring that claims submitted” under their name are “true and correct.”

Perez said that he rarely intervenes on patients with mild disease, following best practices, and said the center, which outsources its coding and billing to another company, was looking into the billing issue and was in contact with CMS for corrections and changes. He did not provide details on the federal investigation into Kurdi but told ProPublica that his colleague was “going through a separation” with the practice.

In all, experts who reviewed ProPublica’s analysis called the findings alarming and validating. They called on government insurers to do something about the fact that a quarter of all patients who got first-time atherectomies — enough to fit in a sports arena — may not have needed them. CMS told ProPublica that it monitors claims data for outliers and can act when it identifies problems, by denying claims, suspending payment or referring questionable providers to law enforcement.

“When we see patterns that are beyond the boundaries of reasonable according to respected peers in the field,” Makary said, “that is a signal that there should be a closer review.”

Editor’s Note

ProPublica reached out to every doctor named in our story through multiple emails and phone calls, providing questions to the physicians, clinics, hospitals or lawyers. The following doctors, their offices or lawyers did not respond to ProPublica’s questions for this story at the time of publication: David Burkart, Ian Cawich, Thomas P. Davis, Pablo Guala, Omar Haqqani, Syed Hussain, Juan Kurdi, Moinakhtar Lala, James McGuckin, Jim Melton, Rajiv Nagesetty, Daniel Simon, Pushpinder Sivia and Harold Tabaie. Dr. Bhaskar Purushottam and Monument Health, where he works, both declined to comment. Riverside Healthcare in Illinois, where Hussain has worked since September 2022, also declined to comment on the doctor’s practice.

In addition to the doctors quoted in the story, the following doctors responded to ProPublica’s findings.

Maryland vascular surgeon Dr. Samer Saiedy told ProPublica that Medicare claims data doesn’t include enough details to provide a full picture of why he may have treated a patient with an invasive procedure. At his practice, patients are only given the option of invasive procedures, he said, if they have severe pain and have already tried less aggressive approaches first. “If you look at atherectomy only, and you narrow down, yes, I’ll be an outlier because I do a lot of claudicants for severe symptoms after we do the medical treatment,” he said. “They cannot walk through the pain, they’re already on blood thinners, they’re already on this and already on this. We’re going to do something.”

Saiedy also said the Medicare reimbursement data is misleading. Saiedy, who has made about $23.5 million from Medicare in reimbursements for atherectomy procedures over five years, according to federal data, said the payments cover all clinic expenses and are not going to him directly. “You have to look at the overhead of the practice,” he said. “That includes nurses, anesthesia, leases for the equipment, rent.”

California interventional radiologist Dr. Malwinder Singha, who received $23.8 million in Medicare reimbursements for atherectomy procedures over five years according to federal data, echoed Saiedy’s concerns. “It is devoted to running of the [office-based laboratory] and only a tiny fraction is earned by the operator,” he wrote in an email to ProPublica. “I have to pay my employees and expenses for all the supplies (wires, balloons, stents, atherectomy catheters, etc.), imaging equipment, [electronic medical records], facilities rent, etc.”

Singha also took issue with the use of claims data to identify clinical outliers. "It does not take into account the patient population I see and the severity of their disease," he said. He added that outpatient facilities are safe, and their patients are satisfied with their care. "What I and my colleagues do is safe and effective," he said. "There are hundreds of office based labs who treat thousands and thousands of patients. The adverse event rate is miniscule."

Interventional radiologist Dr. James McGuckin, who received $17.2 million in Medicare reimbursements for atherectomy procedures over five years, treats “a significantly high-risk patient base” who are at-risk for amputation, said his attorney, David Heim, in an email this past August. Earlier this year, the Department of Justice sued McGuckin for submitting false claims to the federal health care programs for “medically unnecessary invasive peripheral artery procedures,” allegations that Heim had called “provably wrong.” His lawyers have moved to dismiss the case.

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

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