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Controlling costs: We can do more to contain overutilization and use of unproven orthopedic treatments
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During the recent health care financing discussions, claims were made that financial incentives in the current fee-for-service system reward physicians for using “unproven” and at times “unnecessary” treatments. Because of procedure-driven payments, it was proposed some physicians were profiting from performing additional treatments or studies. Currently, reimbursements for many procedures do not require agreed-upon medical indications or proven beneficial outcomes. It was also stated that if “unnecessary,” “unproven” and “not-based-on-outcomes studies” treatments were eliminated, national medical costs could be reduced by one-third.
As orthopedists, have we done enough to curtail some aspects of overutilization of some unproven services and treatments? What can we do to police ourselves or encourage more waiting for the necessary outcomes studies?
All of us have seen occurrences involving creative marketing efforts designed to promote new products and/or encourage a surgeon to utilize the newest treatment. Often these promotions are self-aggrandizing and promise a new treatment that is performed exclusively by a given surgeon in the community. News releases by a company, hospital and/or surgeon may claim to be the first in the area to offer a given procedure These new treatments usually are associated with hype and “buzz words” that imply outcomes that are often out in front of supporting science.
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Over the years there have been a number of examples of these fads, some ending in less then desired results. In the 90s thermal capsulorrhaphy was touted as “shrink wrapping the shoulder” and marketed to surgeons and the public as an alternative to shoulder stabilization surgery. Also, holmium YAG lasers were sold as mechanisms to safely ablate knee tissue in a time-saving, safe and efficient manner. As we found out, that was not true as proposed.
Marketing plans
Another example of marketing directly to patients and surgeons without long-term data to substantiate the claims was seen in the release of gender-specific implants in the last decade. That marketing brought in many women to their surgeon requesting the female knee; however, the claims of improved outcomes made to sell and market these devices have not been confirmed with outcomes data. There are many examples of other treatments and devices that have been marketed before the data warranted widespread application such as: mini-incision hip surgery and certain disc and nucleus replacement devices.
Overutilization without data
A long standing marketing strategy we have seen again recently is for a company to make new equipment available on a per-case rate, as a lease or purchase by the clinician or institution for minimal upfront capital. They then present financial numbers to the physician demonstrating their return on investment based upon a certain amount of treatments (utilization) — with more treatments usually meaning more income.
Currently, an example I believe of another such treatment that is being over utilized while lacking basic science and outcomes data is a new craze in sports medicine. It involves using platelet-rich plasma (PRP) as an injection of concentrated blood platelets (spun down version) that are proposed by some as a fairly unsophisticated growth factor delivery system. The widespread clinical use has been popularized following anecdotal case reports in the sports pages of its use in high-profile athletes. There currently is a lack of published peer-reviewed data and scientific clinical studies documenting its benefits in all the different scenarios in which it is being used. The studies and documentation needed to develop the clinical indications for its more generalized use still are a considerable time away.
Because PRP is derived from the patient’s own blood without extrinsic manipulation such as adding drugs, factors or devices, there is no meaningful regulatory oversight. One controlling factor currently is some insurance coverage denials for reimbursement pending some meaningful publications documenting effectiveness. Yet, some patients I have talked to about their treatments have paid cash based on the explanations they are given.
We all want to help our patients, but why are we seeing increased utilization by some physicians while the majority are asking for more evidence? Proponents and sales personnel have argued that with the PRP treatments some people get better and it is safe. We must remember the placebo-effect rate in some degenerative arthritis studies can reach 30% and many of the musculoskeletal symptoms where it is being used will improve spontaneously with time using a common sense approach. Just because we do not have an effective treatment for a specific condition, it is not necessary to over utilize an unproven treatment.
Some surgeons are already talking about the second-generation PRP uses, proposing platelet lysates which can be prepared in larger quantities and stored by cryopreservation. There will be and are those also injecting growth hormone, other concentrated factors and even stem cells into the joint. One good aspect is the more a patient’s own blood products are manipulated and or enhanced; the more regulatory oversight will come into play. The research and documentation necessary to gain FDA approval will slow some of the enthusiasm for empirically expanding applications of this technology. However, as long as physicians enter informed contracts with individual patients and do not ship products across state lines many of these types of treatments are available on a caveat emptor basis.
The future treatments in medicine will require more outcome data and even now we should try and utilize techniques and devices that have longer-term clinical outcomes data and have supporting scientific data for our applications. By doing this we will silence some of our critics and stem the perceived need for a more regulations over physicians to control costs. This may contribute to preserving more of our decision-making abilities in patient care.
A note from the editors
For more on PRP, see our Cover Story.
Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; e-mail: OT@slackinc.com.