by Annie Waldman

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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........

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