New Bill Aims to End Racial Disparities in Amputations

Lizzie Presser

October 19, 2020

On Friday, Congressman Donald M. Payne Jr., a Democrat from New Jersey, introduced a sweeping bill to reduce unnecessary amputations and address racial disparities that were the subject of a ProPublica story investigating why Black Americans were three times more likely to undergo diabetic amputations than others. The Amputation Reduction and Compassion Act of 2020 was introduced five months after the ProPublica investigation showed how government and hospital policies obstruct equitable care for at-risk patients.

The bill proposes major reforms that seek to address policy gaps explored in the article. Today, about half of patients with peripheral artery disease — a condition in which clogged arteries limit the flow of blood — are asymptomatic, and primary care physicians are not always reimbursed for screening. But catching and treating the disease, which is often caused by diabetes, is critical to preventing unnecessary amputations. The bill seeks to ensure that all at-risk patients can obtain a screening at no cost. It requires that Medicare and Medicaid cover the tests, as well as private insurers.

The ProPublica article also focused on how patients often undergo diabetic amputations without arterial testing beforehand. That testing, either with duplex scans or angiography, can show where blood flow is blocked and can indicate whether an intervention can restore blood flow before surgeons resort to amputation. But nationwide, more than 30% of patients don't get arterial testing before amputation. One doctor likened this to removing a woman's breast after she felt a lump, without first ordering a mammogram. The bill proposes that Medicare only pay for an amputation caused by vascular disease or diabetes if the patient has received arterial testing within three months of the surgery.

"The greatest problem with peripheral artery disease is that it can go undetected for years and lead to limb amputations that could be avoided with early detection," said Congressman Payne, who launched the bi-partisan Congressional Peripheral Artery Disease Caucus with Congressman Gus Bilirakis, a Republican from Florida, in 2019. Payne said the bill provides resources to screen-at risk patients and educate doctors, which in turn will reduce racial disparities in amputations. Five co-sponsors, all Democrats, have signed onto the bill, including Congressman Bobby Rush, from Illinois, Congressman Ruben Gallego, from Arizona, Congressman Bennie Thompson, from Mississippi, Congresswoman Eddie Bernice Johnson, from Texas, and Congresswoman Lisa Blunt Rochester, from Delaware.

Rush and Gallego joined the effort after reading the ProPublica article on the work of Dr. Fakorede, a cardiologist who is reducing amputation rates in Mississippi and advocating nationally for safeguards for patients. "I was shocked and disturbed by the investigative article published earlier this year in ProPublica," Rush said by email. "The article succinctly highlighted the financial incentives to amputate diabetic patients' limbs rather than invest earlier in preventive screenings, particularly for poor Black and Brown patients who are disproportionately and discriminatorily overlooked until it is too late."

After reading the ProPublica article, Gallego was also galvanized to craft legislation to reduce unnecessary amputations. His office reached out to medical experts, including Dr. Fakorede, and other key stakeholders, like the American Diabetes Association. "It is truly disturbing that race and economic status are the two biggest indicators of whether someone with peripheral artery disease will have their limb amputated," he said.

The American Diabetes Association is one of the most influential lobbies on issues related to diabetes in the United States, and prompted by the ProPublica article, it introduced an initiative to reduce unnecessary amputations earlier this year. The organization supports this legislative effort. Tracey D. Brown, their CEO, is particularly shocked by how many of these amputations are preventable. "Policies that make screening and treatment for conditions that cause amputations are urgently needed," she said, after reading the bill.

Dr. Ronald Dalman, President of the Society for Vascular Surgery, said he would have to review the bill before commenting on its specific proposals. He said that while many factors lead to amputations, and preventing them involves more than just testing, "to the extent to which vascular disease does contribute to the risk for limb loss, we support all efforts to ensure that patients get the testing and care they need."

The bill also attempts to better align Medicare payments with the American Heart Association and the American College of Cardiology guidelines on peripheral artery disease; the groups recommend arterial testing before amputation. Dr. Marie Gerhard-Herman, who co-chaired the committee on these guidelines, called the bill "a crucial start in the crusade to save legs." Dr. Michelle A. Albert, president of the Association of Black Cardiologists, added, "Similar to COVID-19, peripheral artery disease care and outcomes can no longer be dictated by racism and zip code."

Lizzie Presser covers health, inequality and how policy is experienced for ProPublica.

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