The Abuse Of Arthroscopy?

There has always been an uneasy relationship between the british medical profession and BUPA the UK's biggest private medical insurer. This is particularly so in orthopaedics where surgeons are very industrious and BUPA picks up the cost. The latest battleground is arthroscopic surgery of the knee.

There has been no increase in the fees paid to surgeons by BUPA for the best part of a decade. In the old days the British Medical Association had its own fee schedule, but this was considered uncompetitive by the predecessor to the Competition Commission, which gave the insurers the upper hand. The surgeons being a resourceful lot realised that even if the cost per case remained the same, doing more surgery made it pretty irrelevant. And this is where arthroscopy comes in. There are two types of arthroscopy as far as the insurers are concerned. Just taking a look, for which the fee is around 瞿250, and doing something inside the knee, for which the fee is around 瞿600. As a quick wave of a shaver blade or the odd biopsy can mean 瞿350, it comes as no surprise that the "look see" arthroscopy has become an endangered species.

In addition to this, convincing a patient to undergo an arthroscopy is much easier than for major surgery. A quick look in with telescope, day case procedure, low risk of complications is an attractive option for a troublesome knee. Even if, as is often the case it all takes much longer to recover than expected, and the procedure turns out to be a bit more than the patient bargained for.

So BUPA has realised that there are lots of arthroscopies being done, the indications for which are to say the least a bit woolly. Some surgeons do far more than others. This may of course mean that this signifies they have busy practices with a lot of deserving patients. It may of course indicate that not all are necessary. The solution as far as BUPA is concerned is to try and put a stop to over servicing. Rather than tackling those surgeons who are obviously practicing on the wilder shores of surgery, which might have been more sensible, they are having a go at all knee surgeons. They have commissioned a review of all the indications for arthroscopy by Bazian an outfit which has "independent" expertise in evidenced based healthcare. The result is a document entitled "Clinical best practice in knee arthroscopy, which is full of tables and a colour coding system not dissimilar to that used by supermarkets to indicate the harmful ingredients in food. To top this BUPA now requires surgeons to justify why an arthroscopy is required by provision of relevant documentation by the consultant before they will sanction payment.

This is all wrapped in conciliatory language about what is best for their clients. It is of course all about cutting costs, by attempting to take over the decision making process of the professionals by applying a list of criteria devised by people who would not know one end of an arthroscope from another if they saw one.

What BUPA will come to realise is that the medical profession, orthopaedic surgeons in particular are a slippery lot. If hurdles are put in their way they will simply adapt to circumvent them. All the relevant paperwork will duly be honed to fulfill the necessary criteria.

There are sharp practitioners in all walks of life. BUPA should get on and identify each of them properly and deal with them. Instead they are in danger of creating a bureaucratic monster taking up valuable time and money to administer which will not reduce the amount of surgery performed, and will cause massive resentment among their clients. The cry of "My surgeon says I need an arthroscopy, but why aren't you prepared to pay for it?" will be hard to silence. Worse still may be litigation from clients forced to follow the route of self pay surgery which cures the condition BUPA refused to pay for. There is nothing worse for an insurance company, than to be seen wanting when it is time to pay up. The competition won't be slow to announce that they prefer to leave decision making to the professionals and will honour any reasonable claim.

It would be a simple matter to analyse the outcome of surgery carried out by consultants who are causing concern by contacting the clients and requesting clinical information. The risk of investigation would make many surgeons more wary of how they behave.

The majority of knee surgeons are acutely aware of their reputations within the community. After all the patients all attend the same social activities. The news of operations that don't work or worse still make things more painful travels fast. Asking permission to operate is therefore intensely irritating. You can only infer so much from a meta analysis. Experienced surgeons are the only ones who can correlate the clinical findings with the internal pathology in any one individual. It is an insult to imply that they do not fully understand the criteria for surgery.

So is the whole process about saving clients from unnecessary pain and suffering?

Not really. It is all about money and an attempt by BUPA to limit its liabilities. They should admit as much to their clients and see what the reaction is.

The choice lies between believing an insurance company which says that statistically you don't need an operation and a professional who has examined your knee and says you do. Both have a financial interest in the transaction. One loses the other gains. But only the surgeon might have to explain to you afterwards why surgery hasn't worked and believe me that is not in anybody's best interests.