The Problem with Shortsighted Care for Long-term Conditions

Many of the arthritis patients I see describe a similar, frustrating and painful routine.  Someone living with osteoarthritis in his knee, for example, wakes up feeling stiff and swollen.  But moving around, warming the knee up, makes it feel better. Until mid-day, when it begins to hurt again.

The patient takes some over-the-counter NSAIDs.  Usually that will take the edge off, enough to keep on with the day.  In a few hours the discomfort is back; the patient takes more NSAIDs, and the process repeats itself.  This cycle is usually worse for rheumatoid arthritis patients, whose disease affects multiple joints and can be more debilitating.  When patients reach a tipping point, they end up in my office. 

These patients deserve more than a quick handshake and a prescription.  They need a health care provider who will listen to their experience; someone who also will take the time to educate them about their condition, its cause and how optimal treatment is multipronged. 

For my patients, that typically includes an anti-inflammatory and physical therapy.  This is where insurers line up their road blocks.  

In some cases, reimbursement for physical therapy is too skimpy to offer patients any lasting benefit.  Some companies in New York City pay as little as $50 per visit, essentially making it nearly impossible for  therapists to be able to afford to provide proper care. Patients get an ice pack, a heating pad and 15 minutes on a stationary bike.  What they actually need is real physical therapy, for a period of weeks or months, that includes strengthening and therapeutic exercises.

Insurance barriers make medication access a challenge too.  In some instances, insurance coverage still perpetuates quick fixes – low-cost generic opioids, for example, which temporarily mask the pain and cost the patient little but don’t solve the underlying problem and have helped to create other problems such as the current opioid epidemic.  Most patients are better off taking prescription NSAIDs, which actually address inflammation. But insurers have road blocks here too.  

To achieve true relief, an arthritis patient may need high doses of the anti-inflammatory medication.  The challenge is that high doses can lead to gastrointestinal issues for some people. A prescription combination of NSAID and a GI protectant offers a safer alternative to patients who need it, but insurers or their pharmacy benefit managers often substitute what I prescribe for what they prefer.  For instance, they’ll offer the patient an NSAID and a GI medication separately, even when the prescribed medicine carries a “do not substitute” label from the Food and Drug Administration.

At every turn, insurers seem to be skimping, stalling and biding their time.  They know that, through job transitions, life changes or personal choice, patients switch from insurer to insurer often.  If they can hold out long enough, the expenses of treating arthritis properly will become somebody else’s problem. In fact, if they kick the can down the road far enough, Medicare will pick up the tab.

Physicians like me are tired of this game.  Shortsighted care and quick fixes are no solution for a long-term condition like arthritis.  Patients deserve quality of life and effective, long-term management of their disease. That requires a care team, and an insurance company, that think long term.

Craig Antell, DO, is a clinical instructor in the Department of Rehabilitation Medicine and Director of Ambulatory Orthopedic Rehabilitation at New York University’s Langone Health.

This post is part of IfPA’s “By All Accounts” blog series.  Each month, a different guest author – and a different story – adds a new piece to the common narrative of how insurance practices meant to control costs are instead hurting patients.

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