Knee surgery review process under fire
Bupa has defended the introduction of a new process that will see some funding requests for surgery referred for a second view on whether they are clinically appropriate and thus eligible for funding.
Since May 23rd, all knee arthroscopies performed on Bupa customers have had to go through this process. Surgeons must complete a one page form explaining the clinical indication for the procedure and confirming whether more conservative treatments have already been tried.
Bupa claims that most cases will be approved for funding the next working day. However, those that fall outside “published evidence-based guidelines” will be sent to an “expert clinical adviser” for a second view on whether the procedure is “medically necessary”. This process is expected to take a further two working days.
The move has elicited opposition from surgeons and raised concerns among some intermediaries but the insurer claims that it is acting in its members interests by investigating “unexplained variation” in the number of arthroscopies performed, which may indicate over-treatment.
The British Orthopaedic Association (BOA), the British Association for Surgery of the Knee (BASK) and the Federation of Independent Practitioners (FIPO) have issued a statement opposing “a proposal which devalues the clinical and personal relationship established between consultants and their patients.”
“Any second assessment of the need for surgery made without seeing and examining the patient and without taking in to careful consideration the clinical findings, co-morbidity, lifestyle, activity and patient’s aspirations could only lead to some inappropriate decisions,” said FIPO vice chairman Richard Packard. “This cannot be in the patient’s best interest.”
FIPO claims that many consultant orthopaedic surgeons, including those at the Royal National Orthopaedic Hospital, have “on a matter of principle” refused to sign the forms. This has resulted in the insurer “attempting to divert patients to other surgeons, some of whom do not even perform knee surgery”, according to FIPO.
Dr Annabel Bentley, medical director for Bupa Health & Wellbeing, told Health Insurance that “the vast majority” of consultants were successfully completing the review process.
“In the few cases where a consultant is refusing to complete and sign the form, we are offering alternative knee consultants for the member to see and in almost all of these instances we are finding that patients are switching to these alternative consultants,” she said.
Dr Bentley confirmed that Bupa is looking into a single claim that the name of a non-knee specialist was given to one Bupa member but said there had been no confirmation of this to date.
‘Driving up quality’
Dr Bentley said the rate of arthroscopies performed on Bupa customers, which is more than twice that recorded by the NHS, and the fact that some surgeons perform three times as many as others, warranted further investigation.
“As a healthcare organisation without shareholders we have to respond to make sure funds are used appropriately,” she said. “And as one that supports customers we need to ensure that our members are having fast access to appropriate treatment and not being exposed to unnecessary risks from surgery.”