The newly introduced CMS model, which introduces prior authorizations for some traditional procedures, could lead to increased administrative burdens and potentially cause delays to care.
CMS’s Wasteful and Inappropriate Service Reduction model, which aims to cut down on costs, includes adding prior authorization arthroscopy for knee osteoarthritis.
The move to implement prior authorization for the procedure also has the potential to reduce clinical judgment, according to Sophia Ly, research fellow, and Eric Smith, MD, chairman of the department of orthopedics of New England Baptist Hospital.
Note: Responses were lightly edited for clarity and length.
Question: What impact will the new CMS model have on traditional Medicare procedures, including arthroscopy for knee osteoarthritis?
Sophia Ly and Dr. Eric Smith of New England Baptist Hospital (Boston): Arthroscopy for knee osteoarthritis has been found to provide only minimal short-term benefit and does not improve long-term pain or function in knee degenerative disease. For this reason, it is not routinely recommended for osteoarthritis, particularly in the absence of mechanical symptoms. However, knee arthroscopy can sometimes serve as a bridge to total knee arthroplasty. Arthroscopy allows the surgeon to visualize and address certain knee conditions causing pain and dysfunction, such as loose bone fragments or meniscus tears and evaluate the condition of the joint prior to deciding on a TKA. While the clinical benefits are temporary, short-term pain relief and improved knee function can buy a patient some time before a more invasive surgery such as TKA becomes necessary.
The new CMS model aims to reduce low-value care and contain costs, which is a commendable goal. However, introducing prior authorization requirements for traditional Medicare services raises significant concerns. Increased administrative burden and potential delays in care may limit timely access to procedures that can improve patients’ daily functioning and quality of life. Providers will be forced to weigh pre-approval processes against the risk of post-service reviews and potential claims denials or nonpayment. Moreover, shifting decision-making to technology companies and algorithm-driven systems rather than clinical judgement threatens to undermine individualized patient assessment, which risks shared decision-making. Algorithms use large data sets and may rely on standardized criteria, which may not capture the nuances of a patient’s unique medical history, comorbidities, or personal goals.
Pain is inherently subjective, which many of the traditional treatments address, and patients have diverse functional goals and lifestyle needs. Broad restrictions assume a one-size-fits-all approach, which does not reflect real-world patient care. Prioritizing restrictions through technology based prior authorization models can inadvertently overlook important patient-specific factors that a physician would naturally consider during an in-person evaluation. The narrow indications for arthroscopy – limited to mechanical symptoms, acute meniscal tears in younger patients, and septic arthritis – further restricts the ability to tailor care for individual patient circumstances while requiring higher burden of proof on providers seeking approval outside these criteria.
While overuse of knee arthroscopy should certainly be avoided, it remains important to preserve flexibility for surgeons and patients to decide on the best treatment approach. Ultimately, policies intended to reduce unnecessary procedures should not inadvertently hinder personal care or weaken physician-patient relationships. Careful implementation and thoughtful oversight will be crucial to avoid unintended consequences from the reliance on artificial intelligence and machine learning that compromise patient outcomes.
