The insanity of covering a $50,000 knee operation but not a relatively cheap injection

Many health insurers say procedures are not "medically necessary," when in fact such treatments could save the companies, and patients, lots of money. (Getty Images / iStockphoto)

Why give someone with bum knees a once-a-year injection costing as little as a few hundred bucks when you can instead make them undergo complicated knee-replacement surgery costing tens of thousands of dollars?

That, in a nutshell, is one reason the U.S. healthcare system is the most expensive in the world.

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It's also where Hollywood resident Jere Rosenberg now finds himself.

The 69-year-old has painful osteoarthritis in his knees, often making it difficult to get around. It's the most common form of arthritis, affecting about 27 million Americans. Cartilage in the joint breaks down as you get older and bones start rubbing together.

When he was covered by Medicare, Rosenberg had no problem receiving annual injections of hyaluronic acid, a thick, gooey lubricant that eases stress on joints. The Food and Drug Administration approved such treatment for arthritic knees in 1997.

Last year, however, Rosenberg switched to coverage under his wife's Anthem Blue Cross insurance plan, which significantly reduced his monthly premiums but also resulted in Anthem saying it wouldn't cover the hyaluronic acid shots.

His experience reveals the frequently arbitrary — and misguided — approach many insurers bring to healthcare coverage.

Although the injections are approved by Medicare and the FDA, Anthem took its cue in part from the American Academy of Orthopaedic Surgeons, which announced in 2013 that hyaluronic acid "is no longer recommended" for osteoarthritis of the knee.

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"Although a few individual studies found statistically significant treatment effects, when combined together in a meta-analysis the evidence did not meet the minimum clinically important improvement thresholds," Dr. David Jevsevar, lead author of the academy's study, said at the time.

I spoke with Jevsevar this week. He said the study was never intended to guide insurance decisions. It states prominently that "medical care should always be based on a physician's expert judgment and the patient's circumstances."

"I don't think hyraluronic acid should be used as a front-line treatment," Jevsevar told me, "but that doesn't mean I don't think it should be used in some cases."

The Arthritis Foundation takes a similar stance. "While studies of hyaluronic acid injections have occasionally yielded disappointing results, many doctors who treat osteoarthritis say that the weight of scientific evidence — and their own clinical experience — suggests that a shot in the knee can produce significant relief for some patients," it says.

Dr. Steven Sampson, founder of the Orthohealing Center in West Los Angeles and a specialist in bad knees, told me that "hyaluronic acid can be very effective for people with mild to moderate osteoarthritis."

"It might not work for everyone," he said, "but it's definitely something you want to consider before looking to more invasive procedures."

By that, he means knee-replacement surgery.

Yet a surgical solution is now in the cards for Rosenberg because his insurer, Anthem, will cover the operation. It likely will cost more than $50,000.

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Compare that with the roughly $1,000 cost of the annual injection of hyaluronic acid that's worked just fine for the past few years.

Or a cost of about $300 if hyaluronic acid is purchased from a Canadian pharmacy (which isn't legal under U.S. law but which many cash-strapped Americans do nevertheless).

"It's crazy," Rosenberg said. "I just don't understand Anthem's thinking. It seems so short-sighted."

Suzanne Zagata-Meraz, an Anthem spokeswoman, said the company's experts looked at "the most recent clinical evidence" and determined that hyaluronic acid injections do not improve the well-being of osteoarthritis patients.

"Neither the American College of Rheumatology nor the American Academy of Orthopaedic Surgeons advocate for the use of [hyaluronic acid] injections to treat osteoarthritis of the knee," she said.

That's just not true. As I've already noted, the academy says the opinion of doctors should always come first, and many doctors favor giving the injections a try.

The American College of Rheumatology, for its part, "supports patient access to appropriate therapies including hyaluronic acid injection," according to a position paper on the subject.

The organization "recommends the use of intra-articular hyaluronic acid injection for the treatment of osteoarthritis of the knee in adults," it says.

Zagata-Meraz declined to comment on the rheumatology group's position paper or my conversation with Dr. Jevsevar.

In any case, Anthem isn't alone in citing such medical associations in denying coverage of hyaluronic acid shots.

Blue Shield of California is currently notifying doctors that, beginning in June, it too will no longer cover the injections. "These services are considered NOT medically necessary based upon review of evidence and guidelines of professional societies such as the American Academy of Orthopaedic Surgeons," it says.

Again, nope.

It's hard not to suspect that, as a growing number of aging Americans succumb to arthritic knees, insurance companies are looking to save a buck by limiting people's treatment options.

Rosenberg's situation also illustrates the larger problem of dozens of health insurers having dozens of inconsistent coverage standards, often undermining the medical judgment of doctors who have direct contact with patients.

This can leave many patients feeling that they have no choice but to accept a more invasive — and expensive — procedure solely because it's covered by the insurer and thus represents a cheaper out-of-pocket alternative.

That, of course, is a foolish way to run a healthcare system.

I'm not saying a Medicare-for-all approach would solve everything. Other countries with such systems limit patient choices and may require long waits for elective procedures.

But it seems clear that a single-payer insurance arrangement would help prioritize medical needs over profit-seeking. It also would facilitate standardized care so that treatment options are consistent for all patients, and hopefully based on sound medical data rather than dubious decisions.

"Patients want peace of mind that they exhausted conservative options before undergoing invasive surgery," Sampson at L.A.'s Orthohealing Center said.

In other words, they want to know that their doctor has the flexibility to try different approaches before breaking out the scalpel.

Insurers should appreciate such a notion — it could save them tons of money.

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And America's knees aren't getting any younger.

David Lazarus' column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to david.lazarus@latimes.com.

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