UK health insurer tries to cut funding for inappropriate knee surgery

BMJ 2011; 343 doi: (Published 02 August 2011) Cite this as: BMJ 2011;343:d4965
  1. Ingrid Torjesen
  1. 1London

A row has erupted between the UK private health insurer Bupa and a group of the country’s top orthopaedic surgeons, after Bupa accused some surgeons of carrying out knee procedures on patients without good medical reason.

Bupa, which funds around 19 000 arthroscopies every year, undertook a review of knee arthroscopies among its insured customers and found that the standardised event rate was more than twice as high among them as it was among NHS patients. Furthermore, some surgeons were more than three times as likely as others to carry out the procedure on Bupa patients.

Annabel Bentley, medical director of Bupa’s UK Health and Wellbeing Division, said, “We know as well that there are wide variations within the NHS, so the variations could be even greater than that in some parts [of the country].”

Bupa then decided to implement a medical review process for knee arthroscopy to weed out procedures that were not clinically necessary. This required surgeons to complete a form before eligibility for funding was granted. The form gave information such as indications for surgery; whether any imaging had taken place; what, if any, conservative treatment had been tried; and whether there was any clinical evidence of mechanical joint locking.

Dr Bentley said, “Our rationale for taking action is that we have observed a significant variation in the arthroscopy rate, and as a healthcare organisation with a responsibility to its members we are responsible for their funds and for ensuring that we provide funds for appropriate clinical treatments.

“We are allocating funds in line with clinical best practice in accordance with relevant published evidence based guidelines. We will pay for a knee arthroscopy when it is in line with clinical best practice; we will not pay when it is poor practice.”

Bupa would not fund arthroscopy for treatment of osteoarthritis without mechanical locking, for example, because there was clear evidence that it was “ineffective and not clinically appropriate,” Dr Bentley said.

The British Orthopaedic Association has urged surgeons to boycott the form, which, it says, undermines surgeons’ clinical judgment.

Peter Kay, president of the British Orthopaedic Association, said, “A pre-authorisation process containing limited clinical information will not address variation and would not stop a poorly practising surgeon, should they exist, filling the form in such a way as to ensure the surgery is funded.”

He questioned why Bupa had refused to make it known to individual surgeons that they had high procedure rates or to “report the surgeons to the medical directors of the hospitals they work in or inform the [regulator] if they have the evidence they claim.”

He suggested that a “blanket process of review of all surgical decisions” failed insured patients and undermined most surgeons who have practised appropriately for years and whose reputations would have largely prompted referral to them in the first place.

Bupa has received 3000 requests from doctors for arthroscopy funding since the review system was implemented in May. In most cases doctors had completed the form, Dr Bentley said. Where they had objected, doctors had been allowed to provide the information through copies of medically relevant letters, records, and scan reports.

She added that a wide ranging review of worldwide guidelines for arthroscopy had been conducted to inform the medical review process, and this would be published shortly.

Bupa introduced a similar review system several years ago for hysterectomy when an audit by the Royal College of Obstetricians and Gynaecologists showed no symptoms in the wombs of some women who had undergone the procedure.


Cite this as: BMJ 2011;343:d4965

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