Blue Cross reverses decision, will pay for knee arthritis shots

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Blue Cross Blue Shield of Michigan has reversed its decision to stop covering an anti-arthritis injection for knees that some doctors insist helps patients but others contend is little better than a placebo.

Blue Cross informed medical providers last week that it will continue paying for hyaluronic acid injections, also known as viscosupplementation therapy, as it reviews additional information about their effectiveness.

Michigan's largest health insurer had planned to stop paying for the injections starting April 1. That initial decision, announced in January, followed a review by Blue Cross of medical studies that questioned the injections' effectiveness.

Had Blue Cross gone forward and stopped coverage, patients who opted for the knee joint lubricating shots would have had to pay out of pocket, which could cost roughly $450 to $1,000.

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"There is great controversy regarding the effectiveness of this treatment nationally," Blue Cross spokeswoman Helen Stojic said in a statement.

"Many health plans – including some in Michigan – have opted to no longer pay for the injections. We are in the process of communicating to our members who are using the treatment to let them know about the ongoing review," the statement said.

Blue Cross' reversal came after pushback from some patient advocates and orthopedic doctors, including members of the Michigan Orthopedics Society, who say the injections help many arthritis sufferers by reducing pain, improving mobility, and delaying the need for a knee replacement.

Knee replacement surgeries, which are covered by private insurance and Medicare, can cost $28,000 or more when including physical therapy expenses.

"At least two-thirds of my patients with mild to moderate arthritis get a pretty significant benefit from these shots," said Dr. Joseph Guettler, an orthopedic surgeon with Beaumont Health.

For the other third of his patients, such as those who are bone-on-bone and not candidates for injections, "sometimes the arthritis is too far gone and they really need to move onto something like knee replacement," Guettler said.

Still, Guettler emphasized that even successful injections don't make the arthritis go away; they generally buy patients "a few years" before needing a replacement.

"I have some patients who I told two years ago they need knee replacement, based on their X-rays," he said. "They decided to try these shots and they come back two, two and a half years later for a second round of shots and I say, 'Where have you been? Did you get your knee replaced?' They said, 'No, I've been great. I want my shots again.'"

'Lack of Efficacy'

But not all doctors are convinced that patients get much benefit from the shots, which essentially inject lubricating fluid into ailing knee joints.

The American Academy of Orthopedic Surgeons, following a review of multiple patient studies, stopped recommending hyaluronic acid injections for knees in 2013 "based on a lack of efficacy, not on potential harm."

More recent research involving over 86,000 Humana insurance patients suggested that knee injections add millions of dollars a year in unnecessary costs because patients will ultimately end up getting joint replacements.

Such doubts have prompted some health insurers to stop covering the injections, including Grand Rapids-based Priority Health, which ended its coverage in 2014.

However, Medicare currently still covers hyaluronic acid injections for patients every six months.

"The most recent comprehensive reviews comparing (hyaluronic acid) to steroid and corticosteroid injections indicate no clinical benefit for either pain reduction or improved physical functioning," Aaron Miller, a Priority Health spokesman, said in an email.

Dr. Brian Hallstrom, a University of Michigan orthopedic surgeon, once regularly gave the injections, but has since mostly stopped after he came to doubt their effectiveness.

"I gave these injections for the better part of 10 years," he said in a phone interview. "While there are exceptions, the vast majority of people didn’t seem to get any benefit from it."

Hallstrom said medical studies have found that some patients may experience a slight improvement, but usually not enough to be clinically significant.

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"There is certainly a small percentage of people who are really glad they got these injections," Hallstrom said. "But the hard part is if you look at the studies that compared these injections to just a saline injection (the placebo), there is a small percentage of people who have a good response to a saline injection. The effect of hyaluronic acid is not much different than placebo."

Life-Changing

Still, some patients say the injections are life-changing.

Robert Willard, 73, works as general manager at the Knee Institute & Regenerative Medicine in West Bloomfield, where he received hyaluronic acid injections in both knees about two years ago.

Before the injections, Willard said he had trouble getting out of a chair and going down steps. He often awakened in the middle of the night from the pain. Had the injections failed, he was going to get knee replacements.

But the injections worked, he said, allowing him to forgo knee replacements for now.

"Now I can get out of a chair with no problem. I can go down stairs without thinking twice about it—and I sleep through the night," Willard said.

Willard says the vast majority of Knee Institute patients who get the injections see improvement in their arthritis.

"This stuff actually works and we've had a lot of patients come through here," he said.

A course of treatment generally includes three to five hyaluronic acid injections spread over three to five weeks. A single-shot treatment is available for a higher price and uses a bigger needle. Proponents say the effect of the shots can last six months or longer.

Crucially, hyaluronic acid injections do not damage remaining joint cartilage, a danger with repeated cortisone injections.

Many doctors urge patients to hold off on getting knee or hip replacements for as long as possible because artificial joints eventually wear out. Although artificial joints can themselves be replaced, the outcome for a second replacement, called a revision, is generally not as great as with the first.

Dr. Ramsey Shehab of the Henry Ford Health System, who has been doing hyaluronic acid injections for 12 years, said about 90% of his patients have received some benefit from them.

How much they benefit depends on factors such as their degree of arthritis, activity level, and weight.

"If it's the right patient, they usually benefit from it," he said.

Henry Ford Health System owns Health Alliance Plan, a Detroit-based insurer that covers hyaluronic acid injections.

In a written response to Free Press questions, Blue Cross Medical Director Jerry Johnson said the Blues decided to continue covering the injections for now after meeting with doctors who presented articles "that proposed a different look at how to compare treatments."

"The primary concern of the doctors is that this leaves them with few therapeutic options to offer their patients with osteoarthritis," Johnson said. "This is not totally true—but the concern is understood. Physical therapy with therapeutic exercise, (anti-inflammatory drugs), topical analgesic therapy, intra-articular corticosteroids and orthotic bracing are all alternatives that are covered."

He continued, "Making a procedure available simply to have an 'option' to offer is not justified if the option offered does not really impact the patient’s clinical outcome in a positive way."

Blue Cross hasn't said when it anticipates its final decision on the injections.

Contact JC Reindl: 313-222-6631 or jcreindl@freepress.com. Follow him on Twitter @JCReindl.

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