Is it ethical to offer bad pain care just because it's covered?

[drusso]

The Insurance Coverage Bioethics Dilemma - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"The only way that I can see that the doctor would be able to avoid a serious medical ethics dilemma (and a possible malpractice case) by steering a patient toward covered care of a bad or “less good” solution is with expanded informed consent. That means that the doctor goes out of his or her way and documents that they have discussed with the patient that they are choosing a worse option for treatment based solely on insurance. That would include not only a written document but a documented extensive discussion back and forth with the patient. That would also require the patient to acknowledge in writing that this conversation took place and that they are choosing the worse option solely because it’s covered.

The upshot? I can find no way that medical bioethics would allow for steroid injections in knees or SI joint fusions as part of routine care given that there are better options with high-level research support. However, despite this, these procedures remain common. The question we need to ask ourselves is, why?"

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[sloh]

I don't recommend steroid injections or SI fusions. There's more evidence wrt PRP for knee OA but not enough where I strongly recommend it. Just educate the patient and let them make the decision.

 

[deleted284725]

This is a bit melodramatic.

 

[drusso]

This is a bit melodramatic.

Can you elaborate? Do you dispute that access to pain care is an equity issue?

 

[hyperalgesia]

The Insurance Coverage Bioethics Dilemma - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"The only way that I can see that the doctor would be able to avoid a serious medical ethics dilemma (and a possible malpractice case) by steering a patient toward covered care of a bad or “less good” solution is with expanded informed consent. That means that the doctor goes out of his or her way and documents that they have discussed with the patient that they are choosing a worse option for treatment based solely on insurance. That would include not only a written document but a documented extensive discussion back and forth with the patient. That would also require the patient to acknowledge in writing that this conversation took place and that they are choosing the worse option solely because it’s covered.

The upshot? I can find no way that medical bioethics would allow for steroid injections in knees or SI joint fusions as part of routine care given that there are better options with high-level research support. However, despite this, these procedures remain common. The question we need to ask ourselves is, why?"

This is just one of the many utterly corrosive and irredeemably toxic manifestations of population healthcare and its real-world implementation - the "insurance state".

Policies are defined in LCDs and they are merely followed by technicians employed by the insurance/state networks.

It's all perfectly ethical from a population healthcare perspective.

 

[drusso]

This is just one of the many utterly corrosive and irredeemably toxic manifestations of population healthcare and its real-world implementation - the "insurance state".

Policies are defined in LCDs and they are merely followed by technicians employed by the insurance/state networks.

It's all perfectly ethical from a population healthcare perspective.

 

[deleted875186]

I cannot understand how no insurrance covers PRP injections, blows my mind. They are allowed to make medical decisions for us.

 

[deleted131481]

The best care is often not the cheapest.

Getting paid to do a procedure is an inherent COI.

 

[Agast]

This guy needs to review the definition of malpractice.

 

[deleted875186]

I do think joint CSI get a bad wrap. They buy people time before a TKA or THA. I will get one before I need a joint when I’m 60. Of course I will also try a PRP first as well.

 

[Laryngospasm]

Do you offer intraarticular steroids to folks who can’t have replacement and no coverage or money for prp?

 

[painfree23]

Is OP saying when he gets knee pain he will opt for the tka before trying a steroid shot? I’m calling bs

 

[Agast]

I do think joint CSI get a bad wrap. They buy people time before a TKA or THA. I will get one before I need a joint when I’m 60. Of course I will also try a PRP first as well.

Am I the only still doing genicular nerve RFA?

Even if it doesn’t pay that well, it really impresses people. Think if it as your Costco chicken loss leader.

 

[NJPAIN]

Am I the only still doing genicular nerve RFA?

Even if it doesn’t pay that well, it really impresses people. Think if it as your Costco chicken loss leader.

What’s your most successful technique for genicular RFN? Is your technique greatly modified from the original description? Are you using Coolief? Oreos claims good results but my recollection is that he is using venom needles and bipolar technique.

I’ve not had good results but perhaps my technique stinks. I’d love to try again if I can get it to work.

 

[NJPAIN]

What’s your most successful technique for genicular RFN? Is your technique greatly modified from the original description? Are you using Coolief? Oreos claims good results but my recollection is that he is using venom needles and bipolar technique.

I’ve not had good results but perhaps my technique stinks. I’d love to try again if I can get it to work.

Along the same lines, am I the only one not eating Costco chicken?

 

[Agast]

What’s your most successful technique for genicular RFN? Is your technique greatly modified from the original description? Are you using Coolief? Oreos claims good results but my recollection is that he is using venom needles and bipolar technique.

I’ve not had good results but perhaps my technique stinks. I’d love to try again if I can get it to work.

I’m too poor for Coolief T_T

I use Stryker venom. At some point I’m going to trial that newer RFA probe whose name I can’t remember.

I started doing two burns. One at about 3/4th depth of the shaft and then pulling back to about 2/3 depth (guesstimating lesion sizing coverage). To try to accommodate variation in pathway down the shaft.

We don’t actually get the Costco chicken but there’s this street taco kit and guacamole singles I make sure to get every time.

 

[deleted284725]

Can you elaborate? Do you dispute that access to pain care is an equity issue?

It’s certainly an issue that is representative of larger problems in our healthcare system. It’s just the language used in this article when we’re talking about knee and SI injections is a bit over the top. Makes it seem like we’re discussing some epic life saving care. I’m not saying it doesn’t matter. I’m just saying this guy makes it sound like it’s one of the greatest travesties in medical history lol.

 

[deleted131481]

Am I the only still doing genicular nerve RFA?

Even if it doesn’t pay that well, it really impresses people. Think if it as your Costco chicken loss leader.

Along the same lines, am I the only one not eating Costco chicken?

I’m too poor for Coolief T_T

I use Stryker venom. At some point I’m going to trial that newer RFA probe whose name I can’t remember.

I started doing two burns. One at about 3/4th depth of the shaft and then pulling back to about 2/3 depth (guesstimating lesion sizing coverage). To try to accommodate variation in pathway down the shaft.

We don’t actually get the Costco chicken but there’s this street taco kit and guacamole singles I make sure to get every time.

Just bought organic chicken thighs today for $27. I don't know how much per pound but it seemed like a lot. We frequent the street taco kit and quinoa salad - kids are a big fan.

Anecdotally my genic RFA seems to have better results since doing the modified technique posted somewhere on this board - probably about what you're doing at 3/4 depth on the superiolateral and medial and about 1/2 on the inferomedial. Been thinking to add a 2nd burn, likely will.

 

[drusso]

Just bought organic chicken thighs today for $27. I don't know how much per pound but it seemed like a lot. We frequent the street taco kit and quinoa salad - kids are a big fan.

Anecdotally my genic RFA seems to have better results since doing the modified technique posted somewhere on this board - probably about what you're doing at 3/4 depth on the superiolateral and medial and about 1/2 on the inferomedial. Been thinking to add a 2nd burn, likely will.

Do you think that the work is appropriately valued...ie is the Juice Worth the Squeeze?

 

[hyperalgesia]

Those of you doing geniculars, are you using fluoro or U/S?

 

[painfree23]

Those of you doing geniculars, are you using fluoro or U/S?

Fluoro, but want to learn with U/S, any recs?

 

[hyperalgesia]

Fluoro, but want to learn with U/S, any recs?

Ask @oreosandsake to do hands on training for your group.

 

[deleted131481]

Do you think that the work is appropriately valued...ie is the Juice Worth the Squeeze?

A genicular RF gets 2.5 rvu. This converts to roughly 5 packs of chicken thighs from Costco. Certainly a lumbar RF for a little more time will get a lot more chicken thighs.

Fluoro, but want to learn with U/S, any recs?

I tried it with a US method I read targeting around genicular arteries - was not able to find them easily, took too long so abandoned it pretty quickly.

 

[deleted185747]

Sorry, the correct denomination is not chicken thighs. It’s tendies. Now that that’s cleared up: we are using coolief at the VA for geniculars and have about 50% with good relief for a year and 40% of them relief for 4-6 months. Some don’t get relief even though the dx block (single session, 3 nerves) helped more than 50%.
fuoro guided with images saved for future reference.
I tell the fellows no repeat steroid into peripheral joints unless the eventual destination is a trashcan. One is ok, must use ropivicaine 0.2% as this is the least chrondrotoxic.
Insurance COI? Absolutely! My becoming a provider who accepts the plan you’re allowing the plan to exist! Go out of network and do what’s right.
Apes together strong

 

[oreosandsake]

A genicular RF gets 2.5 rvu. This converts to roughly 5 packs of chicken thighs from Costco. Certainly a lumbar RF for a little more time will get a lot more chicken thighs.


I tried it with a US method I read targeting around genicular arteries - was not able to find them easily, took too long so abandoned it pretty quickly.

US guided in office. The blocks x3 take about 60 seconds. Even easier than fluoro as you don’t wait for that AP and lateral. You can see the nerve if you have a good machine and know what you’re looking for.

can do combined US and fluoro for the RF. I use venom and the outcomes are great

 

[oreosandsake]

What’s your most successful technique for genicular RFN? Is your technique greatly modified from the original description? Are you using Coolief? Oreos claims good results but my recollection is that he is using venom needles and bipolar technique.

I’ve not had good results but perhaps my technique stinks. I’d love to try again if I can get it to work.

 

[deleted131481]

US guided in office. The blocks x3 take about 60 seconds. Even easier than fluoro as you don’t wait for that AP and lateral. You can see the nerve if you have a good machine and know what you’re looking for.

can do combined US and fluoro for the RF. I use venom and the outcomes are great

For diagnostic block US- so can you routinely see the nerve? If not are you just doing landmark at mid to posterior shaft? I was thinking of doing this and not worrying about finding the genicular artery. Was not sure how reproducible I'd be on fluoro.

 

[oreosandsake]

For diagnostic block US- so can you routinely see the nerve? If not are you just doing landmark at mid to posterior shaft? I was thinking of doing this and not worrying about finding the genicular artery. Was not sure how reproducible I'd be on fluoro.

Yes. greater than 90 percent of the time. Though on the tibia it’s often difficult to differentiate between the pes tendons and the nerve

 

[cowboydoc]

#medbikini ???

 

[heathermed]

anyone have US pics of the nerves?

 

[cowboydoc]

In this pic, placement strictly fluoro or U/s, too? Looks high for a generic fluoro target, but can't argue with u/s placement. Since doing blocks with u/s, I've found the nerve location/course to be quite variable.

I'll try to post some u/s pics tomorrow, if oreos won't make too much fun of me.

 

[oreosandsake]

Ultrasound Diagnosis

There’s a pic and video on the page

there was a cadaver study that showed it’s not next to the artery like 30 percent of the time. You also see them on MRI if you’re looking for them

 

[oreosandsake]

Ultrasound Diagnosis

There’s a pic and video on the page

there was a cadaver study that showed it’s not next to the artery like 30 percent of the time. You also see them on MRI if you’re looking for them

Video will also show you the periosteum membrane overlying the nerve. This is why the blocks are so efficacious and the rfa totally misses (for so many people)

my own observation.
Once you pierce this membrane a small amount of fluid will travel very far. You’ll get the field block and you’ll look on fluoro and think, this is where it’s at! Go back and use the same spots on fluoro eith rf probe and nothing happens... for some people

 

[Crybaby]

Thanks Oreos, great info. I hope to transition to this when I feel comfy enough with US. May hit you up for some more advice if that is ok.

 

[oreosandsake]

In this pic, placement strictly fluoro or U/s, too? Looks high for a generic fluoro target, but can't argue with u/s placement. Since doing blocks with u/s, I've found the nerve location/course to be quite variable.

I'll try to post some u/s pics tomorrow, if oreos won't make too much fun of me.

dual modality. i usually bipolar both on the femur 2-3x along it's course and monopolar on the tibia. often get over 18 months with this technique.

with US you can go after the recurrent n from the peroneal as well but I haven't needed to do that. another great technique is to hydrodissect out the infrapatellar br of the saphenous nerve. all those patients with medial knee pain a little distal to the patella? or have edema collecting along the medial knee? try this. you'll be surprised

 

[Ferrismonk]

On the flip side, is it ethical to only offer treatments that aren't covered, and thus unavailable to the patient leaving them with no treatment at all.

 

[drusso]

On the flip side, is it ethical to only offer treatments that aren't covered, and thus unavailable to the patient leaving them with no treatment at all.