SBAR: Hospital Charges Almost $10K for Knee RF

[drusso]

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Situation: 57 year old female recreational tennis player with bilateral knee pain (mild/moderate OA and patelofemoral syndrome) worsening over 3 years goes to see orthopod. Orthopod recommends steroid injections x 3 and refers to PT. Patient has short-term improvement, but symptoms return. Ortho tells her "You're not a candidate for TKA yet," and refers to Pain MD in same hospital group. Pain MD recommends bilateral knee genicular RF. Pain MD does one set of diagnostic genicular blocks and says, "let's burn." Patient gets burned...and then gets the bill. 8 weeks out patient is still symptomatic, but now has burning sensation on medial knee L>R and is self-referred to me for "consideration of regenerative medicine options?"

Background: Site of service (SOS) differentials for between HOPD and office settings can be as high as 5X. Moreover, based upon Level II evidence, a simple LP-PRP injection could be considered prior to progressing to a neuro-ablative procedure at literally one-tenth the cost.

Assessment: This patient got rooked by the SOS-HOPD criminal enterprise.

Recommendation: If you're letting your employer get away with these kinds of extractive business practices then you've got to do a gut-check. No one goes into medicine to be a "patient broker" for a broken system. $10K+ (not including the PT, orthopod injections, etc) is phenomenal waste of resources and is just going to line the pockets of fat-cat hospital CEO's and their C-Suite Lackeys. She gave me permission to post a redacted copy of her EOB with the hopes that other doctors won't let this kind of abuse be perpetuated upon unsuspecting or uninformed patients.

EOB attached.

 

[lobelsteve]

So thc is legal for docs in your state.

Put down the bong russo.

 

[Ducttape]

was the pain MD PP or hospital employed?

the crook here is the pain doc that decided to do the RFA even though the diagnostic blocks did not help. could very well have been a PP pain doc. could have been worse - that doc might have referred to an OON ASC.

and anesthesia services should never be needed for RFA - in office, ASC or HOPD based...

 

[drusso]

So thc is legal for docs in your state.

Put down the bong russo.

You can look at the hospital cost-to-charge ratio's yourself to see how much she was over-charged:

HCUP-US Cost-to-Charge Ratio Files

But, if you don't believe that she rooked you're in the minority. And, it happens everyday:

Texas teacher thought he had great health insurance. Now he's stuck with a $109,000 ER bill.

SIS could really get out in front by doing some very simple health services research and showing the public how jacked up prices are for common pain & spine-related procedures...

 

[lobelsteve]

I meant that you are complaining about the charges. The problem is the care was unnecessary, likely not done well, not needed to be done in that venue. But then you go overboard and say she should have bought your magic beans instead.
Care should include Xray, injection of steroid or VS. Failure of that prompts MRI, PT. RF not indicated for knees not bad enough to operate on. IT should be reserved for those who failed surgery, or are too sick for surgery. Magic sauce should be reserved for research.

 

[drusso]

Magic sauce should be reserved for research.

I agree with you...except Level II Evidence Magic Sauce. In any event, Magic Sauce would have been a cheaper, possibly more effective, harm reduction intervention.

Now, I've got squadoosh to offer her because you can't unboil an egg...I did offer to testify on her behalf. Possible DRG candidate if the burning pain doesn't go away

http://www.physiciansforpatients.org/home

 

[thecentral09]

Do you know the diagnostic blocks didn’t work?

 

[drusso]

Do you know the diagnostic blocks didn’t work?

No pain diary available to review so unclear. Do you typically do a block, have the patient get up off the table, do a deep knee bend, and then sign them up for a $10K procedure at the hospital?

 

[Orin]

The benefit of a diagnostic block would be most apparent immediately with the local anesthetic and so minutes is really all that is necessary, if rapid acting LA was used. Would you prefer they wait days/weeks/months before scheduling?

I'm just not clear about why LP-PRP? Is it the lack of durable harm with the lower cost? In the case in front of you, if it's just a peripheral neuropraxia from a thermal lesion, it gets better right? Why not try your magic sauce and see?

Any placebo is good enough for some folks, especially one that agrees with their world views.

 

[thecentral09]

N

No pain diary available to review so unclear. Do you typically do a block, have the patient get up off the table, do a deep knee bend, and then sign them up for a $10K procedure at the hospital?

no, pain diary with listed pain provoking activities and burn it if over 75%, prob repeat if 50-75, but leave it up to patient.
Can you post your data for prp?

 

[Ducttape]

Please post your level II evidence for PRP.

Then please post her insurance approving a prior authorization for the procedure.

 

[drusso]

Please post your level II evidence for PRP.

Then please post her insurance approving a prior authorization for the procedure.

Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: a randomized controlled trial
David Buendía-López, Manuel Medina-Quirós, Miguel Ángel Fernández-Villacañas Marín
Journal of Orthopaedics and Traumatology: Official Journal of the Italian Society of Orthopaedics and Traumatology 2018 August 20, 19 (1): 3
1

BACKGROUND: Knee osteoarthritis (OA) is a disease with a high prevalence in the adult population. Nonsteroidal anti-inflammatory drugs (NSAID) or intra-articular injections [hyaluronic acid (HA) or platelet-rich plasma (PRP)] can provide clinical benefit. Magnetic resonance imaging (MRI) has proven to be useful for the evaluation of cartilage volume and thickness in knee osteoarthritis. The purpose of this study was to evaluate the benefit provided by PRP injection in comparison with hyaluronic acid and NSAID in knee OA patients and to compare the radiographic evolution at the 52-week follow-up.

METHODS: One hundred and six patients were enrolled and randomized according to the Spanish Rheumatology Society knee osteoarthritis diagnosis criteria. Ninety-eight patients completed the study (33 received NSAID treatment, 32 a single hyaluronic acid injection and 33 a single PRP injection). Patients were prospectively evaluated at baseline, 26 and 52 weeks using the Western Ontario McMaster Universities osteoarthritis index (WOMAC) and the visual analogue scale (VAS), and at baseline and 52 weeks with X-ray and MRI.

RESULTS: A 20% decrease in WOMAC pain and increase in physical function was found in 30 and 24%, respectively, of those patients who received PRP treatment, at the 52-week follow-up. WOMAC pain and VAS improved in the hyaluronic acid and NSAID groups. However, better results were obtained in the PRP group compared to hyaluronic acid and NSAIDs (P < 0.05). No differences in Kellgren-Lawrence or cartilage thickness progression were found.

CONCLUSIONS: Leukocyte-poor platelet-rich plasma (LP-PRP) injections are better in terms of clinical improvement with respect to HA injections or oral NSAID treatment in knee osteoarthritis patients at the 52-week follow-up. Moreover, a single LP-PRP injection is effective. However, LP-PRP has no influence on cartilage progression.

LEVEL OF EVIDENCE: Level II.

And, for the GIGO evangelists...

Arthroscopy. 2017 Mar;33(3):659-670.e1. doi: 10.1016/j.arthro.2016.09.024. Epub 2016 Dec 22.
Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials.
Dai WL1, Zhou AG1, Zhang H1, Zhang J2.
Author information

Abstract
PURPOSE:
To use meta-analysis techniques to evaluate the efficacy and safety of platelet-rich plasma (PRP) injections for the treatment knee of osteoarthritis (OA).

METHODS:
We performed a systematic literature search in PubMed, Embase, Scopus, and the Cochrane database through April 2016 to identify Level I randomized controlled trials that evaluated the clinical efficacy of PRP versus control treatments for knee OA. The primary outcomes were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores. The primary outcomes were compared with their minimum clinically important differences (MCID)-defined as the smallest difference perceived as important by the average patient.

RESULTS:
We included 10 randomized controlled trials with a total of 1069 patients. Our analysis showed that at 6 months postinjection, PRP and hyaluronic acid (HA) had similar effects with respect to pain relief (WOMAC pain score) and functional improvement (WOMAC function score, WOMAC total score, International Knee Documentation Committee score, Lequesne score). At 12 months postinjection, however, PRP was associated with significantly better pain relief (WOMAC pain score, mean difference -2.83, 95% confidence interval [CI] -4.26 to -1.39, P = .0001) and functional improvement (WOMAC function score, mean difference -12.53, 95% CI -14.58 to -10.47, P  < .00001; WOMAC total score, International Knee Documentation Committee score, Lequesne score, standardized mean difference 1.05, 95% CI 0.21-1.89, P = .01) than HA, and the effect sizes of WOMAC pain and function scores at 12 months exceeded the MCID (-0.79 for WOMAC pain and -2.85 for WOMAC function score). Compared with saline, PRP was more effective for pain relief (WOMAC pain score) and functional improvement (WOMAC function score) at 6 months and 12 months postinjection, and the effect sizes of WOMAC pain and function scores at 6 months and 12 months exceeded the MCID. We also found that PRP did not increase the risk of adverse events compared with HA and saline.

CONCLUSIONS:
Current evidence indicates that, compared with HA and saline, intra-articular PRP injection may have more benefit in pain relief and functional improvement in patients with symptomatic knee OA at 1 year postinjection.

LEVEL OF EVIDENCE:
Level I, meta-analysis of Level I studies.

 

[drusso]

Then please post her insurance approving a prior authorization for the procedure.

Hmm, explain to me in as much detail as you can how *ANY* insurance company's prior authorization procedure is related to a treatment's effectiveness. Specifically, consider commercial insurance companies and worker comp carriers with respect to treatments like neuromodulation, RFA, etc. Then, can you think of other examples of prior auth procedures for treatments that are known to be harmful but are still prior authed?

 

[Timeoutofmind]

Clinical and radiographic comparison of a single LP-PRP injection, a single hyaluronic acid injection and daily NSAID administration with a 52-week follow-up: a randomized controlled trial
David Buendía-López, Manuel Medina-Quirós, Miguel Ángel Fernández-Villacañas Marín
Journal of Orthopaedics and Traumatology: Official Journal of the Italian Society of Orthopaedics and Traumatology 2018 August 20, 19 (1): 3
1

BACKGROUND: Knee osteoarthritis (OA) is a disease with a high prevalence in the adult population. Nonsteroidal anti-inflammatory drugs (NSAID) or intra-articular injections [hyaluronic acid (HA) or platelet-rich plasma (PRP)] can provide clinical benefit. Magnetic resonance imaging (MRI) has proven to be useful for the evaluation of cartilage volume and thickness in knee osteoarthritis. The purpose of this study was to evaluate the benefit provided by PRP injection in comparison with hyaluronic acid and NSAID in knee OA patients and to compare the radiographic evolution at the 52-week follow-up.

METHODS: One hundred and six patients were enrolled and randomized according to the Spanish Rheumatology Society knee osteoarthritis diagnosis criteria. Ninety-eight patients completed the study (33 received NSAID treatment, 32 a single hyaluronic acid injection and 33 a single PRP injection). Patients were prospectively evaluated at baseline, 26 and 52 weeks using the Western Ontario McMaster Universities osteoarthritis index (WOMAC) and the visual analogue scale (VAS), and at baseline and 52 weeks with X-ray and MRI.

RESULTS: A 20% decrease in WOMAC pain and increase in physical function was found in 30 and 24%, respectively, of those patients who received PRP treatment, at the 52-week follow-up. WOMAC pain and VAS improved in the hyaluronic acid and NSAID groups. However, better results were obtained in the PRP group compared to hyaluronic acid and NSAIDs (P < 0.05). No differences in Kellgren-Lawrence or cartilage thickness progression were found.

CONCLUSIONS: Leukocyte-poor platelet-rich plasma (LP-PRP) injections are better in terms of clinical improvement with respect to HA injections or oral NSAID treatment in knee osteoarthritis patients at the 52-week follow-up. Moreover, a single LP-PRP injection is effective. However, LP-PRP has no influence on cartilage progression.

LEVEL OF EVIDENCE: Level II.

And, for the GIGO evangelists...

Arthroscopy. 2017 Mar;33(3):659-670.e1. doi: 10.1016/j.arthro.2016.09.024. Epub 2016 Dec 22.
Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials.
Dai WL1, Zhou AG1, Zhang H1, Zhang J2.
Author information

Abstract
PURPOSE:
To use meta-analysis techniques to evaluate the efficacy and safety of platelet-rich plasma (PRP) injections for the treatment knee of osteoarthritis (OA).

METHODS:
We performed a systematic literature search in PubMed, Embase, Scopus, and the Cochrane database through April 2016 to identify Level I randomized controlled trials that evaluated the clinical efficacy of PRP versus control treatments for knee OA. The primary outcomes were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores. The primary outcomes were compared with their minimum clinically important differences (MCID)-defined as the smallest difference perceived as important by the average patient.

RESULTS:
We included 10 randomized controlled trials with a total of 1069 patients. Our analysis showed that at 6 months postinjection, PRP and hyaluronic acid (HA) had similar effects with respect to pain relief (WOMAC pain score) and functional improvement (WOMAC function score, WOMAC total score, International Knee Documentation Committee score, Lequesne score). At 12 months postinjection, however, PRP was associated with significantly better pain relief (WOMAC pain score, mean difference -2.83, 95% confidence interval [CI] -4.26 to -1.39, P = .0001) and functional improvement (WOMAC function score, mean difference -12.53, 95% CI -14.58 to -10.47, P  < .00001; WOMAC total score, International Knee Documentation Committee score, Lequesne score, standardized mean difference 1.05, 95% CI 0.21-1.89, P = .01) than HA, and the effect sizes of WOMAC pain and function scores at 12 months exceeded the MCID (-0.79 for WOMAC pain and -2.85 for WOMAC function score). Compared with saline, PRP was more effective for pain relief (WOMAC pain score) and functional improvement (WOMAC function score) at 6 months and 12 months postinjection, and the effect sizes of WOMAC pain and function scores at 6 months and 12 months exceeded the MCID. We also found that PRP did not increase the risk of adverse events compared with HA and saline.

CONCLUSIONS:
Current evidence indicates that, compared with HA and saline, intra-articular PRP injection may have more benefit in pain relief and functional improvement in patients with symptomatic knee OA at 1 year postinjection.

LEVEL OF EVIDENCE:
Level I, meta-analysis of Level I studies.

RESULTS: A 20% decrease in WOMAC pain and increase in physical function was found in 30 and 24%, respectively, of those patients who received PRP treatment

...

A 20% decrease in pain occurred in 30% of the patients?!?!?!?

e.g. no better than placebo

How do people get stuff like this published?

Is this what you tell your patients when you consent them? No one would sign up for that.

 

[Ducttape]

Hmm, explain to me in as much detail as you can how *ANY* insurance company's prior authorization procedure is related to a treatment's effectiveness. Specifically, consider commercial insurance companies and worker comp carriers with respect to treatments like neuromodulation, RFA, etc. Then, can you think of other examples of prior auth procedures for treatments that are known to be harmful but are still prior authed?

it doesn't. the question wasn't about treatment effectiveness.

if you want to complain about how much it costs, and how much it costs the patient, then you need to evaluate the cost of the treatment you are suggesting is far superior, in terms of how that will affect the patients wallet.



thanks for the article, my only critiques - does not appear to be blinded (different from randomized) and "However, LP-PRP has no influence on cartilage progression." which would be something very significant if it did as advertised.....

 

[lobelsteve]

Looked at this article, at best placebo response in the PRP, but not one person of the 30/30 in either of the 2 other arms had any response. Nocebo for them. Not adequate blinding? Bias? I will run numbers on validity as soon as I get chance. Looks to be nothing but background noise.

 

[painfree23]

was the pain MD PP or hospital employed?

the crook here is the pain doc that decided to do the RFA even though the diagnostic blocks did not help. could very well have been a PP pain doc. could have been worse - that doc might have referred to an OON ASC.

and anesthesia services should never be needed for RFA - in office, ASC or HOPD based...

genicular rfa is a little painful, some anesthesia is ok

 

[lobelsteve]

genicular rfa is a little painful, some anesthesia is ok

Lido and bupi. No pain.

 

[Ducttape]

genicular rfa is a little painful, some anesthesia is ok

conscious sedation maybe, but you do not need general anesthesia nor should one be billing for a separate anesthesiologist to do GA, as was this case.

 

[drusso]

conscious sedation maybe, but you do not need general anesthesia nor should one be billing for a separate anesthesiologist to do GA, as was this case.

But, it's in the hospital's interest to do this. All the providers involved were employed MD's. No one spoke up for the system nor the patient.

 

[painfree23]

Lido and bupi. No pain.

What size needles are u using? Approach to get to the targets? Do you numb the whole track? I use 27g with lido and bupi but patients just don’t like that. Would love to find an easier way. I do an AP approach with the leg flat and the whole leg raised on some pillows to clear the view for the lateral. Maybe that’s not the best way cuz patients really don’t seem to like it. They do fine with all my other injections under local only.

 

[lobelsteve]

What size needles are u using? Approach to get to the targets? Do you numb the whole track? I use 27g with lido and bupi but patients just don’t like that. Would love to find an easier way. I do an AP approach with the leg flat and the whole leg raised on some pillows to clear the view for the lateral. Maybe that’s not the best way cuz patients really don’t seem to like it. They do fine with all my other injections under local only.

27g 1.25" to raise skin wheal and make tract to that depth. 20G10cm, 10mm tip RF needles. Pull stylet and put on cute little catheter as you approach bone. Inject .2ml lido when you think it will help as you move in. I use approach as per the Choi et al article.

Either leg can get propped oon pillow so knees do not overlap on lateral.