Insurance Study Promoting Alternatives to Hip Arthroplasty

[Tin Soldier]

Has anyone heard of a recent study that insurance companies are using to support an argument that hip arthroplasty (both THR and HR) can usually be treated with alternatives to surgery?  I ask, because Oregon Public Employees Benefit Board (PEBB) is saying that hip arthroplasty is of "questionable medical value" and they are midyear instating a $500 co-pay on top of the deductible, for any spine, knee, shoulder, and hip surgery.  They say that the co-pay is designed to make people look a little harder at alternative treatment options before considering surgery. 

A few problems with their argument:
1.  $500 on top of the co-pay is not going to change my mind, I'm still going to get a new hip when it's bone on bone and horrible ROM.
2.  $500 from each surgery is obvisouly not going to make a dent in the overall cost
3.  Don't you think most primary's (GPs) and surgeons would recommend alternatives first, who the hell wants to go through surgery?  I did PT, Ibuprofen til I was hypertensive, cortizone, looked into arthoscopic, thought about putting it off, and talked to 3 good surgeons.  The answer -  "you need a new hip kid", also it all went to insurance.
4.  Have they modeled the future costs for treating all of the problems associated with not treating hip OA?  gimpy, wornout, alcoholic, morphine-patched, toothless 50 yr olds, depressed and nearly in a wheel chair?  (sorry to be so blunt here).  My point is that we know that there are costs associated with not treating OA, let's look at them and show me the comparisons.

I know we have budget problems, every year the funding gets less and less, insurance covers less and less, that's easy to understand, but give me some data and a report that this $500 co-pay really does work.  Oh and give me the alternatives to bone on bone OA, while you're at it.  I'm just kidding, I already did those and they don't work.  I've asked PEBB several times and they can't seem to provide me with a report or study that supports this.

So in short, is there a recent study that has been circulating amongst insurance companies that is supporting this feeble argument?   Hey, if they want more money, why didn't they just pick this group (ortho surgery) and say we need more money and we're going to charge you.  I'm fine with that, but to make claims like this without backing it up is totally inappropriate, deceitful, and possibly fraudulent. 

[Lori Cee]

Not heard of the study but feel free to let me know about the 'magic wand' that's going to fix OA damage that nobody knows about yet...  Freaking insurance companies.

[halfdone]

HCUPnet provides trend information for the 16 year period: 1993-2008
http://hcupnet.ahrq.gov/HCUPnet.jsp
CCS principal procedure category 153, Hip replacement, total and partial
                                        1993           2008      
Total number of discharges   260,242   436,736
Charges, $ (mean)            21,985      51,360   

No surprise that insurance companies are very anxious to try to address cost trends in hip arthroplasty.

PS Excellent rant TS! 

[Lopsided]

Am I alone with the misguided understanding that the only way insurance companies can make money is by customers getting paid out less, on average, than they paid in?

[Lori Cee]

Am I alone with the misguided understanding that the only way insurance companies can make money is by customers getting paid out less, on average, than they paid in?

I agree that insurance companies aren't charities they are businesses, but what really annoys me is the arguments they come up with to reduce payouts.  I would prefer honesty and be told up front when I renew annually that what I pay isn't enough to cover me for X, Y and Z and then leave it to me to decide whether I want to take the risk that I won't need something that is now an exclusion or co-pay or pay a higher premium to cover the higher outgoings rather than arguments that don't make sense.  To be fair,  not all insurers are created equally and there are some that act more transparently and honestly than others (well at least here in Australia). 

[Tin Soldier]

Thanks for the support on the rant.  If insurance only knew that they could simply barter with the "elective" surgery with me and we could come up with a price for surgery that I would pay.  For a $55k procedure, I'd be happy to pay $2k per hip.  That's $3k more than my deductible.  Instead they ask for a measly $500 and provide me with a worthless argument and tell me to "talk to your primary about alternatives".  My primary, when I asked him why I was so stiff, he bent me around a little, took some x-rays and sent me off to PT without showing the images to an ortho.  I spent 2 months doing very painful stretching with a labral tear and bone on bone OA for nothing.  And my primary is going to tell me about alternatives?  I don't think so. The PT finally said, "this isn't working, I think you need to see an ortho"  That's when I got the golf putter.

BTW - this "insurance companies aren't charities" remarks that I have seen, sort of irritates me.  Yeah we all know that.  So far, I've spent about an 1/8th of what I and my company has put into insurance for the last 20 years.  I don't put $1000 a month into a charity.  I'd love to, but I can't.  I put $1000 a month for 20 years into an insurance company and I'd like to think that when I ask for a little backup and data to support their reasoning, I'd get it.  I sort of feel like telling them that I will happily pay them the $500 for hip no.2 if they hand me a report that supports their argument.

Halfdone - thanks for the numbers, I can understand why insurance companies want to recovery more money.  I'm going to try to get my kids to become ortho surgeons, I hear the pay is good.

 

[halfdone]

Halfdone - thanks for the numbers, I can understand why insurance companies want to recovery more money.  I'm going to try to get my kids to become ortho surgeons, I hear the pay is good.

Likewise!  Ortho and cosmetic surgery are the growth industries of the 21st century.  BTW The US has a healthcare cost problem, which turns into the insurance and coverage nightmare that so many of us experience, because it (with higher ed) is an industry with hugely inefficient practices and uncompetitive industry structure.  In just about every other industry, the US has lower costs. Hips alone are a $5-10billion annual savings opportunity.

[Lori Cee]

Wow - $1,000 a month is massive. (That's more than most people here have go into their retirement fund!)  
I always knew we had it good in Australia but I didn't expect that much of a difference.  My top of the line health insurance for both my husband and I for hospital and extras is $260 a month.  

Things work a little bit differently here I think as our medicare picks up a fair bit as well (at least I know where some of my tax dollars have gone to work this year).  At the end of the day I'll probably end up being out of pocket about $5,000 for bilateral BMHR which I think is pretty reasonable given the actual costs for the surgeon that I have chosen are higher than the amount that the health fund says they will pay for this particular procedure.  I could have had less out of pocket had I chosen a no gap surgeon and anaesthesiologist but I wanted to chose the surgeon.  My surgeon does do some public hospital work and I think that I could have gotten the same procedure publicly in a public hospital but I am pretty sure that I would have had to wait a lot longer to actually get an appointment with him (probably forever since he is a pretty popular 'fixer' of difficult cases) and I wouldn't have had a single room or the same rehab options.

The biggest cost that my health fund will cover will be the hospital stay itself as medicare here picks up the cost of the prostheses.  Just to give you an idea of what things cost here: the surgeon charged me $4800 for the bilateral BMHR of which about half I will get back from the insurer.  I don't have the bill for the anaesthesiologist yet but am expecting it to be about $2800 with about half come back from govt medicare.  All in all, it looks like things are a lot cheaper here.  I also have a $500 excess for the hospital stay and will eventually receive bills for xrays (some back from medicare) and medications (subsided).  My total bill might get that high, but I have two prostheses and a much longer hospital/rehab stay included so we really aren't comparing apples with apples.

All in all, I'm pretty happy with my current insurer but if I was paying that much more, I think I would expect a lot more too.  I expect to be given real reasons for changes to out of pocket expenses from my insurer now so I can make informed decisions about my choice to stay with them and on what type of plan.  You'd certainly expect to be a valued customer after 20 years too and receive at least that courtesy.  Really though shouldn't any customer receive that courtesy?

[Denver_wrench]

"Insurance companies aren't charities..." In the same way that the Mafia isn't a charity. One example might be is that the "cost" of my BHR surgery (before the back-door negotiotiations) is nearly $80,000 us dollars. The cost to have it done at the McMinn Centre by the folks who invented the darn thing is about $18,000. I've personally spent over half that dealing with my hip (not including premiums, which would make it costlier) and tons of time wading through the BS it took to get the surgery. That is in no way efficient, fair, or sensible. I think my Australian brother, British brother-in-law, and Canadian cousins would agree. Make sure you vote.