Bupa defends review process for knee surgery

Bupa is speaking out to defend a controversial review process for knee surgery implemented in May, according to Health Insurance & Protection‘s Nigel Lowry. The procedure requires surgeons to complete paperwork showing a clear cause for performing the surgery, as well as which treatments have already been attempted. That is all well and good. What has raised surgeons’ hackles is an additional clause: cases not meeting what Bupa terms “published evidence-based guidelines” are then forwarded to one of its clinical advisers for a second review.

Lowry quoted the British Federation of Independent Practitioners’ Vice Chairman Richard Packard, who said

Any second assessment of the need for surgery made without seeing and examining the patient and without taking in to careful consideration the clinical findings, co-morbidity, lifestyle, activity and patient’s aspirations could only lead to some inappropriate decisions […] This cannot be in the patient’s best interest.

Bupa’s Dr. Annabel Bentley, Medical Director for Bupa Health & Wellbeing, argued the procedure is justified given the unsettling trends that have developed around knee arthroscopies. The number of arthroscopies performed on Bupa customers is twice that of the British National Health Service, certain doctors perform three times as many procedures as others. “As a healthcare organisation without shareholders we have to respond to make sure funds are used appropriately,” she said.

Lowry stopped short of drawing any broad conclusions, other than to observe that

Bupa is not the only player in the private healthcare market seeking to address unwarranted variation in treatment. Alliance Surgical, a group of consultants working with several major insurers, has reduced the number of operations it delivers to knee pain patients by 25% by developing a single protocol followed by its 1,250 members.

Such is the underlying dilemma of managed care. One can reasonably expect any business to target cost efficiencies, and there is always the possibility that some – if not many – of the arthroscopies in question were unnecessary. However the surgeons also raise valid concerns: at the end of the day everything hinges on Bupa’s experts, who are far removed from the patients in need of care.

This underscores the need for expats to think carefully about the type of care they prefer – some insurers offer both US-style managed care plans and others oriented toward the socialized European health systems. Furthermore, as insurers come under increasing pressure from rising medical costs it stands to reason many will attempt to more tightly control claims spending. It’s a variation on the old principal-agent problem. When it comes to managed care, an expat has little more than her insurer’s word that her best interests are at the heart of the discussion.

Companies mentioned

Bupa International is a segment of the UK’s British United Provident Association Limited. Bupa is a market leader in international health insurance, operating (either directly or through one of its subsidiaries) in countries from Europe to the Middle East and Asia. Bupa reported pre-tax profits up 9% at GBP 464.9 million in 2010, driven largely by its Asian and Australian business segments. http://www.bupa-intl.com