Reimbursement for Cartilage Reconstruction

( tr ) to repay or compensate (someone) for (money already spent, losses, damages, etc): your fare will be reimbursed after your interview

In healthcare we have misconstrued or re-branded this word to mean “payment”, when, in fact, it really means
payment back for a loss of money. It is an insurance term, and quite revealing of the fact that insurance companies regard health care in the same way you might regard a tornado or a car accident- unfortunate, somewhat unlikely, but compensable…up to a point. This pretty much sums up all of what is wrong about private health care in the U.S.,both presently and in all current serious proposals.

Cartilage repair may improve life quality but hardly is in the same category as kidney dialysis or heart transplantation.
It is more in the category of good dental care and hygiene- what person does not know that if you want to keep your teeth, you must take care of them? The same may be true of your joints. And it is also true, like good dental hygiene, that the status of your joints has important implications for the state of your overall health.

Insurance companies care little about this. They care about NOT spending money- your money- that you have paid in premiums.

By the time a procedure is standardized for reimbursement- especially in a dynamic field like cartilage repair-
it is often yesterday’s news. Even after the regulatory authority ( the FDA) allows a product to be sold, it may be years (if ever) before an insurance company will place that procedure on its approved list.

For many years, I was told that ACI could not be done unless a microfracture surgery had been done- and failed- and the patient had suffered for at least 3 months. Whoever thought this up should have been a member of  the Inquisition.  I am quite sure that no class in medical school ever suggested that an inappropriate and failure prone procedure be performed just to help the patient get reimbursement. This is the crazy world we live in.

Recently, insurance companies have backed off on the “microfracture first” canard. Ironically, it is now not too difficult to get ACI paid for just at the time it is becoming outdated in favor of less expensive single surgery procedures.

Those of us in cartilage repair need to make the case that new procedures may be expedient for all as we strive to produce better outcomes at less cost.  This effort should be collaborative with both payers and patients,  a situation that is difficult to achieve when conversations start off in an adversarial way. After all, medical care is all about money.  The +/- approval/disapproval mode of a “reimbursement’ decision should be replaced by an analogue, risk sharing approach; for example, have the patient pay for a portion of the implant, but cover all other expenses (including paying the doctor). Make innovation possible during the multi-year period where outcomes are assessed.  Unless we do something of this nature, payment will always be based upon the view from a rear view mirror, always looking at the past.