It’s no surprise to many that U.S. medical insurance companies seem to be getting more stringent on what procedures they allow to be covered. However, it may seem peculiar that an insurance company would cover a surgery costing tens-of-thousands of dollars, but not a far less expensive, more conservative treatment that may alleviate pain and prevent the need for surgery in some patients.
The L.A. Times recently shed light on the issue of inconsistent standards amongst insurers that often undermine the expertise of physicians who have direct patient contact.They specifically highlighted that Anthem Blue Cross is no longer willing to cover hyaluronic acid (HA) injections for knee osteoarthritis and that other insurance companies are following suit in their reluctance to cover HA injections. For example, Blue Shield will also stop covering HA injections starting in June. For those who are not familiar, HA is a gel-like substance that when injected into the knee, provides lubrication, reduces friction and can alleviate the discomfort associated with knee osteoarthritis in some patients. Despite HA injections being approved by the FDA and Medicare in addition to being recommended by physicians for some patients, Anthem Blue Cross decided that they would no longer be covering the procedure based on a statement made in 2013 from the American Academy of Orthopaedic Surgeons that HA is “no longer recommended” for knee arthritis.
L.A. Times pointed out that the above insurance coverage decision may be misguided and short-sighted as it did not consider physician clinical judgment. The lead author of the 2013 article published by the American Academy of Orthopaedic Surgeons said that their study was not intended to guide insurance decisions and that it clearly stated “medical care should always be based on a physician’s expert judgment and the patient’s circumstances.” The Arthritis Foundation holds a similar position stating that although some research on HA injections has produced disappointing results, many physicians have reported that scientific evidence and their own clinical experience suggests that HA knee injections can provide significant relief in some patients.
The Orthohealing Center’s founder and leading expert, Dr. Steven Sampson, was quoted by the LA times, stating that “hyaluronic acid can be very effective for people with mild to moderate osteoarthritis. It might not work for everyone, but it’s definitely something you want to consider before looking to more invasive procedures. Patients want peace of mind that they exhausted conservative options before undergoing invasive surgery.
This article highlights the ever changing healthcare environment, and the many difficulties that clinicians and patients face with medical care. It’s important for patients to discuss all treatment options with their doctor, and devise the best care plan based on associated risks and benefits with their specific medical condition.