As explained in our last article, there’s more to managing personal health care costs than concentrating on insurance payments and uncovered costs. As health care consumers, we’d all benefit from learning how to determine whether the value of the services—as delivered by a given provider—is worth the cost, potential risk, and benefits.
Here, again, are the four key questions:
- Request evidence for new or continued treatment;
- Ask about your providers’ cost and quality performance and service standards;
- Question what doesn’t seem right about your experience, diagnosis, and treatment;
- Request episode-based cost information.
There’s a good chance that some consumers will dismiss this list outright. Some (perhaps many) don’t feel comfortable questioning their doctors. Older patients may feel that questioning medical decisions or treatment alternatives is beyond their expertise, and that the physician “knows best.”
For others, it just might seem difficult to ask questions if they don’t understand basic anatomy and physiology, let alone recent medical knowledge. The idea of requesting clinical trial results may feel uncomfortable or seem ridiculous.
But consider this: Health outcomes and the growing financial burden of health care services can be life-altering, and the cost will only increase with time. We all have to own the responsibility for better understanding and managing our health, including making better decisions about the value of medical interventions and other services.
What It Means to Question the Evidence
So let’s take a closer look at the first and most important thing that we can do as health care consumers: Question the evidence.
It’s all about identifying and understanding basic criteria. Think about the last time you purchased a car. Did you understand all the internal mechanics and computer systems under the hood? Most likely, you relied on certain key factors when you shopped around, like fuel efficiency, driver ergonomics, passenger seating, cargo room, and repair history. Obviously, making decisions about health care is more nuanced, but with the proper criteria in mind, the choices become clearer, when made in partnership with a provider who is willing to participate in an informed, shared decision-making process. The benefits are not only physical, emotional, and financial; chances of success increase when patients are fully invested in the treatment plan.
Take the case of osteoarthritis, one of most common types of illness that affects us as we age. Indeed, 53 million adults experience one or more of the joint diseases categorized as arthritis. Osteoarthritis is the most frequently diagnosed condition within that category, and is typically age- and/or activity-related. Despite some known risk—and improvement—factors, however, the progression and pain of degenerative joint diseases is unique to each individual.
Alternative Paths in Osteoarthritis Treatment
Typically, patients with osteoarthritis are prescribed anti-inflammatories; supplements; exercise regimens and/or physical therapy; as well as, possibly, joint injections of corticosteroids, hyaluronic acid, or other agents. All of these therapies have side-effects, some of which are damaging. Even the common use of over-the-counter NSAIDs comes with risks.
Unfortunately, while various instruments can measure the severity of arthritis, these tools are inconsistently used to determine treatment. Rather, clinicians often depend on X-rays to determine therapies, rather than taking into account measurement of pain and dysfunction, a practice that potentially leads to overtreatment.
One of the most common overtreatments is joint replacement. Osteoarthritis is a major diagnosis for hip and knee replacements, but there is a growing belief that hip and knee replacements are being overperformed, costing tens of thousands of dollars. One study estimated as much as one third of knee replacements could be inappropriate based on key criteria.
Another problematic treatment involves opioids, which have been routinely prescribed for both chronic pain and post-surgical pain management related to arthritis. Despite indications that these drugs provide no greater pain relief than NSAIDs in arthritis of the hip and knee, providers continue to prescribe them. Even when use of opioids received a cautionary review as a treatment for pain related to osteoarthritis and surgeries by the American College of Rheumatology (ACR), feedback from patients that these drugs should remain available, despite evidence that they are no more effective, weighed in favor of their remaining in use. As a result, there is a risk that arthritis can be a potential gateway for opioid addiction.
Multiple therapies, inconsistent effectiveness, cost variations from zero to tens of thousands of dollars, and outcomes that may be complicated by addiction—these are why health care consumers should begin asking questions about the therapies recommended by physicians.
How Standard Therapies Suddenly Became Ill-Advised
On its website, Cleveland Clinic promotes the use of joint injections to relieve the pain of arthritis in hips and knees. They are not alone among providers who promote this common pain therapy. Yet the evidence about efficacy is questionable, at best. The ACR recently reviewed clinical studies of support therapies specifically for hip, knee, and hand osteoarthritis, and specifically recommended against the following therapies; their findings will be released in guidelines next month:
- Joint Injections:
- Hyaluronic acid injections (hip)
- Platelet-rich plasma injections (hip, knee)
- Stem cell injections (hip, knee)
- Interleukin-1 receptor antagonists
- Chondroitin (hip and knee)
- Transcutaneous electrical nerve stimulation (hip and knee)
- Drugs used more typically in autoimmune diseases or in rheumatoid arthritis:
- Hydroxychloroquine (antimalarial)
- Methotrexate (immunosuppressive)
- Tumor necrosis factor inhibitors
Corticosteroid joint injections, the first line of therapies with joint injections, also have a questionable track record, despite being in mainstream use and remaining as acceptable therapeutics by the ACR guidelines. A 2017 study of corticosteroid injections for knee arthritis revealed that pain was not reduced and that deterioration of cartilage actually worsened. Further, the ACR further investigated negative outcomes with corticosteroid injections in 2018, and found that four negative outcomes warranted more caution because of negative effects on cartilage—as well as fractures and earlier progression to joint replacement.
How to Question the Evidence with Your Provider
Google research about medical conditions is often dismissed by providers as alarmist or misleading—not without cause. But as patient engagement gains credence, some providers are more welcoming of conversations about merit of therapies. What’s needed is the time for longer discussions with providers, coupled with solid research-driven information to patients.recent movements toward engaging patients has some providers more welcoming of the conversations. Yet time does not always permit the extensive discussion needed, and unfortunately many practices have not compiled consumer-directed information that can help them navigate key information.
For that to happen, consumers will need to drive the process of questioning. Here’s how to start with finding the right osteoarthritis treatment:
- Begin a self-education process about your conditions, earmarking important findings or advice. There is good information on the Arthritis Foundation site that explains degenerative joint diseases, and provides findings on activities, e.g. running with arthritis. You can find good information on therapies that are now recommended—for example, the ARC has recently upgraded recommendations for education and exercise, and tai chi in particular—as well as articles on the National Institutes of Health PubMed search engine for health care research.
- Provide a list of questions to your physician about your condition and activities to discuss, including information gleaned from websites, for validation.
- Request information from your physician on how the severity of your arthritis is being measured, what instrument is being used, and the result. You need to determine that quality of life and other measurement criteria are being used for therapeutic recommendations, not just X-rays.
- Seek consistency of treatment plans with your goals. Goals to improve running performance or to reduce pain are very different and require different approaches. You should discuss and seek consensus with your clinicians on a plan to reach your goals, not generic goals.
- Take someone you trust to your appointments, so that you can benefit by support and later confirm the information you received and impressions of the visit.
- Before embarking on a major therapy such as surgery, seek a second opinion from someone who will have nothing to do with your case.
- Ask for articles from randomized trials that show (in numbers) the benefits and harms for any recommended treatment or therapy, prior to agreeing to therapy.
Any consumer with a computer and web browser can participate in a process that leads to becoming more knowledgeable and engaged in how to manage the pain and movement issues associated with arthritis. As for most medical conditions, consumers may well find that much of their status will depend on their own activities and efforts to be pain-free or pain-reduced. Osteoarthritis is a chronic and progressive disease, and the current science has no quick fixes or cures. Therapies must be individually appropriate as well as proven effective to show value for the money spent.
Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.
Image: Matthew Bennett