New and Cool and Not for You—Unfortunately
Traditionally, conservative care meant non-operative care: If a person injured their knee or shoulder, the doctor said, “Let’s try conservative care first and see if you get better.”
This article is adapted from Dr. Stone's book Play Forever.
These days, though, conservative care often means that the insurance company has authorized only physical therapy or medications, with the aim of delaying a full workup or surgical repair as long as possible. But conservative care may not be in the patient’s best interest.
Let’s take my favorite subject: a knee injury. The data shows that if a patient twists their knee, hears a pop, and the knee swells, there is a 90 percent chance that a significant injury to the meniscus, articular cartilage, or ligaments has occurred. The current understanding of these tissues is that they are crucial to knee function, rarely heal on their own, and are best treated with surgical repair as soon as is practical.
In the case of the meniscus cartilage—when a patient hears a pop and the knee swells—this means a significant portion of the tissue has been torn. This won’t heal on its own. Non-operative care, such as physical therapy, means the torn tissues are exposed to repetitive motion, which, in this instance, further damages the tissue beyond the ability of the surgeon to repair it. Unrepaired meniscus tears lead to arthritis. Not very conservative. Even worse, “standard” surgery (meaning that surgical procedure reimbursed by insurance) often means tissue removal called a meniscectomy. More technically complicated and more expensive options are meniscus repair or meniscus replacement. Both of which, if done early, can save the knee rather than exposing it to further injury. But your insurance may not cover it and therefore the surgeon may not do it.
In the case of ligaments such as the ACL, the longer the knee is left unstable, the more the ligaments and the secondary restraints on the side of the knee become stretched. This means a higher chance of a secondary injury to the supporting structures, such as the meniscus. It also leads to a worse result when surgery is eventually performed—even more so if the patient is young. Outside donor tissue is often the best choice for many people as it avoids the second site surgery where the patellar tendon or the hamstring tendons of the patient are harvested, “robbing Peter to pay Paul”. But as many insurance companies won’t reimburse for the donor tissue, patients face losing one part of their knee to rebuild another.
The same is true for the articular cartilage, the bearing surface of the joint. Acute damage that leads to knee swelling never heals. Articular cartilage has no nerve supply, so the damage may not initially be painful. But if it is left unrepaired, the lesions expand into early arthritis and persistent pain. The repair techniques, such as articular cartilage paste grafting has demonstrated long-term effective relief1however approval for cartilage repair remains elusive.
Today, in the 21st century, the ability to make an extremely accurate diagnosis of joint injuries depends upon the combination of obtaining a careful history (i.e., talking to the patient about exactly how the damage occurred), an experienced examiner, accurate X-rays, and a high-field, high-quality MRI. As it is far cheaper and much more efficient to fix injuries sooner rather than later, it is pennywise and pound foolish to skimp on these resources after significant joint injuries. Hopefully, it will become widespread knowledge that early repair is far better for the patient than false conservative care.
Since health insurance plans are so costly, however, most employers now buy the lowest-cost coverage for their employees. This means these employees can only go to doctors who accept the lowest fees, and these doctors can only use devices that are “approved” (i.e., cheap) for treatment. Most of the new, cool, and hopefully better products are not reimbursed, or the hospital will not add them to the formulary. This means surgery centers or hospitals will not get reimbursed if they are used.
This is having a dramatic impact on the utilization of state-of-the-art devices and techniques. The number of patients allowed coverage for one of the new and improved implants now available is declining rapidly. The most significant change is that “out-of-network benefits” are being reduced to almost nothing—despite the language on expensive healthcare plans. “New and cool and not for you” is not what a patient wants to hear, but it is increasingly true.
If a patient buys a more expensive insurance plan, believing it will empower them to go to other doctors and get what those doctors determine is best for treatment, the patient is often mistaken. The out-of-network benefit coverage they buy today has hidden caps. At an outpatient surgery center, for instance, most plans now have a cap of $300 to $400 per day. That might cover a few more minutes in an operating room, at best.
True private insurance plans without caps are rare. So while healthcare costs are being reduced overall, today’s doctors-in-training are exposed only to the limited techniques and devices allowed under current plans. How are they going to expand their knowledge and develop into superstars of medical care?
The pendulum of controlling healthcare costs has swung too far. Anthem BlueCross now lists almost all but the most basic therapies as follows: “Cannot be approved. Needs more data.” Even when controlled clinical trials and meta-analyses show the efficacy of new tools and techniques, the reviews are unwavering: “Not enough studies to approve.” This can be said about nearly every advance in medicine and surgery.
When patients seek expert care, they expect their doctors to have access to and experience with the best tools, the best implants, and the best devices for their bodies. Generic drugs might be okay, but generic knee surgery is not, and generic implants are often simply out of date.
Today, healthcare quality and training are being reduced to the lowest common denominator. This may be a good thing when we are trying to protect the entire population with a minimum of basic care. But it has a chilling effect on the development of new techniques and on the training of doctors.
The solution? Get rid of the insurance regulations and Medicare-type rules that forbid voluntary disclosed additional charges for products and services from which the physician believes a patient will benefit from. Permit doctors to charge (and patients to pay) more than the minimum-set fees. Those who can afford it will pay, and the demand for top-level care will drive innovation. It is time to let doctors be doctors before there aren’t any creative ones left.
You may find more insights into healthcare and medical training in Dr. Stone’s new book Play Forever: How to Recover from Injury and Thrive, on Amazon now.