In 2002, I tore the meniscus in my knee while having a damn good time.
My orthopedist wanted to aggressively diagnosis and treat the injury with an MRI and then surgery but my out of pocket costs for that sequence probably would have been six months of my then limited as a grad student income. That was not going to happen. Instead, he gave me a PT regime that I could do at home and told me that my knee would probably be off for a year but eventually everything would be mostly all right.
And he was right and a recent study in JAMA shows that after a year, PT and surgery have about the same outcomes. Physical Therapy is also a whole lot cheaper than surgery.
TFW not having knee surgery in 2003 due to cost seems to have been a washhttps://t.co/t8dB8H38Jo
— David Anderson (@bjdickmayhew) October 3, 2018
If we are to move towards a system that prioritizes the combination of evidence based care and cost effectiveness, the number of people who get the expensive and non-superior treatment has to fall. In this case, that would mean far fewer meniscus repair surgeries when the injury is straightforward and the patient has no confounding complicating risk factors. And yes, the evidence shows that surgery has a faster return to low pain status than physical therapy but that is a matter of months and the level of pain and dysfunction at a year out are about the same.
From an insurance design perspective, benefits need to evolve. Try to fail which is a common benefit structure in the pharmacy benefit could expand to more physical health interventions where the non-inferior and cheaper alternative is mandated first and then the more expensive alternative is authorized only when the first attempt failed.
An alternative payment mechanism could also be set up where a simple knee meniscus tear triggers an episode based payment that is heavily weighed towards physical therapy. The surgeon would have a strong financial incentive to refer a patient with a simple injury to physical therapy.
Another alternative would be reference pricing where the bundle for meniscus repair is again heavily weighed towards physical therapy but if someone wants immediate knee surgery, they can pay most if not all of the incremental difference in costs.
If we actually want an evidence based medical system where cost is a major decision shaper, then we will need to change incentives to encourage treatment pathways that are less expensive and non-inferior.
Non-inferiority, creaky knees and cost trade-offsPost + Comments (27)