Referral under some Insurers. Is it appropriate?

RE: Referral under some Insurers. Is it appropriate?

grumpyoldman — Sat, 10 Oct 2015 15:13:19 GMT

Myelography is also better with cervical lesions when your trying to distinguish between traction responsive and static lesions , its hard to put 20kg weights on a dobermans jaw and monitor things properly while its out of reach in the MRI room ,the repeat sequencing takes a lot more time with MRI, much quicker to just slapping another plate under it. My only problems were years ago with Conray ,making a few patients seizure ,but that does not happen with Omnipaque.

RE: Referral under some Insurers. Is it appropriate?

grumpyoldman — Sat, 10 Oct 2015 13:48:18 GMT

[quote user="Malcolm Ness"]My experience supported by a critical reading of the literature suggests that in the most common cases (intervertebral disc extrusion) following competent neurological examination and evaluation, MRI offers little, if indeed any, benefit over myelography.[/quote]

The answer to that is yes ,a good myelogram is an excellent diagnostic tool ,if your in possession of Omnipaque and able to perform a lumbar tap , and we do several when funds are limited ,the clients have travel issues and the Burgess MRI van is not here or a short distance away. The paper did say accuracy was just as good as MRI , but you try getting one of our new grads to do a lumbar or cisternal csf tap without holding their hand, in which case you may as well just do it yuorself

? They have all been brainwashed into thinking its a referral procedure and out of their comfort zone and they are all terrified of anything going wrong and the RCVS getting involved.

I would say in my limited experience the MRI is more reliable in helping decide which side to cut and distinguishes arachnoid cysts and tumours better ,but they are much less common and have a slightly more insidious presentation .

What always worries me in these situations is the grade4-5 case presenting as a weekend usually sunday morning emergency with limited funds that does not recover post surgery/myelography. About 10-20% likely . They then go off for a second opinion as a wealthy relative steps in , and the smarmy resident comments "I do not like myelograms did not know this anyone did this anymore". ? why wasn't this dog MRI'd ?

I have played this game before :-)

RE: Referral under some Insurers. Is it appropriate?

Anthony Dennison — Sat, 10 Oct 2015 11:50:42 GMT

Thanks Malcolm, really informative post! I have to admit I've never performed myelography, perhaps it's something I should look into practicing. I have occasional access to cadavers from the RSPCA shelter I do work for, so might start practicing some techniques.

What would you suggest for the low volume, high velocity extrusions? Would they show up on myelography?

RE: Referral under some Insurers. Is it appropriate?

Malcolm Ness — Sat, 10 Oct 2015 10:48:21 GMT

[quote user="ruths"]I'm really interested in the 'intention to treat' argument around 'doing tests' and would very much appreciate a steer in the direction of some literature on this.[/quote]

Good starting point is the Wikipedia entry on Intention-to-treat analysis. From there, I would buy and read a book called "How to read a paper: The basics of evidence based medicine" by Trisha Greenhalgh, published by BMJ. It is quite short (??150 pages) and surprisingly easy to read.

Have you engaged with RCVS Knowledge yet? That is the trendy new name for what was RCVS library. It is now headed up by Nick Royle who was a big cheese in the original Cochrane Collaboration as well as being a really nice, approachable guy. They have started work on developing a veterinary evidence based medicine journal - they have recently appointed an editor - an American called Rich Evans who I know and respect greatly. This is an exciting time for veterinary evidence based medicine; a key principle espoused by Nick Royle and Rich Evans is inclusion so if you are even a little bit interested in the subject (you are clearly more than just a little bit interested) then I would encourage you to get in touch with Nick Royle and Co and get involved.

RE: Referral under some Insurers. Is it appropriate?

ruths — Sat, 10 Oct 2015 10:30:52 GMT

[quote user="Malcolm Ness"]

[quote user="Anthony Dennison"]ower experience levels also led to a longer anaesthetic for a myelography, almost comparable to that of MRI, so they accepted in some case MRI may be the preferred imaging modality.[/quote]

That has been a discussion point in a couple of papers that seemed to have a sub-text of marketing MR for routine spinal use. The argument is completely spurious.

The spinal cord in dogs is small and consequently good MR images need powerful magnets and longish exposures. The additional tissue detail provided by [good quality] MR images is rarely of clinical significance provided a competent neuro exam has been done. If it hasn't then the imaging shouldn't be happening.

Myelography for TL lesions associated with disc extrusions (as the majority of cases in practice are) is a skill that it easier to acquire than the related decompressive surgery; it is inexpensive and safe - the reported complications are variable in number but low in the hands of the competent and almost always the result of technical error. There is a close correlation between what myelography reveals (mainly space-occupying lesions) and what can be done surgically (remove space-occupying lesions).

If comparisons are to be made, they should be done on an "Intention to treat" basis - that means that any cases that miss out on treatment because the investigation is cost-prohibitive (for example, MRI) count as failures. Intention to treat analysis is unpopular amongst narrow, academic types who favour their own expensive techniques, but it is gaining ground in human EBM for the simple fact that it closely reflects the reality of practice and the patient experience.

Having practiced before the MR period (I was one of the first clinicians to regularly use MR in clinical practice) as well as during the MR period, I would not be terribly upset to move into the post-MR period. Loss of MR would have remarkably little effect on the quality of care available to the overwhelming majority of patients. A small (very small) number of patients would lose out - some treatable brain disease relies on MR but they are not common. Very many more patients (and clients) would miss out on pointlessly big bills.

[/quote]

Malcom, thanks for this.

I'm really interested in the 'intention to treat' argument around 'doing tests' and would very much appreciate a steer in the direction of some literature on this.

I'm just starting to think about an audit on the positive predictive value of various tests used in practice and any resdjng I could do would e very helpful

RE: Referral under some Insurers. Is it appropriate?

Malcolm Ness — Fri, 09 Oct 2015 18:47:16 GMT

That has been a discussion point in a couple of papers that seemed to have a sub-text of marketing MR for routine spinal use. The argument is completely spurious.

RE: Referral under some Insurers. Is it appropriate?

Anthony Dennison — Fri, 09 Oct 2015 15:24:46 GMT

This is true - the same papers also said that MRI involves a longer anaesthetic etc. However, some of those review papers also discuss the risks of myelography when undertaken by those less experienced in the technique. Lower experience levels also led to a longer anaesthetic for a myelography, almost comparable to that of MRI, so they accepted in some case MRI may be the preferred imaging modality.

RE: Referral under some Insurers. Is it appropriate?

Bob Russell — Fri, 09 Oct 2015 14:29:07 GMT

Not sure I can see where the BVA or BSAVA have got the 'constructive discussion' bit from. They consider referrals to be limited to those with post graduate qualifications.

Strikes me these two organisations have done bu++er all to deal with the real issues and have achieved little or nothing.

Few of us in first opinion practice benefit from the over zealous in referral practice. Insurance limits should never be regarded as targets!

RE: Referral under some Insurers. Is it appropriate?

Malcolm Ness — Fri, 09 Oct 2015 14:18:33 GMT

[quote user="Braden Collins"] The vet on the show explained it was "crucial" to have an MRI to see what was happening in the joint. An extra how many hunderd/thousand pounds would have been added to the bill for a diagnosis a new grad could make on a thorough clinical exam.[/quote]

Excellent point but if you read another thread you will find someone criticising (I paraphrase) an insurer for not agreeing instantly to their suggestion that MRI was an essential precursor to spinal surgery. My experience supported by a critical reading of the literature suggests that in the most common cases (intervertebral disc extrusion) following competent neurological examination and evaluation, MRI offers little, if indeed any, benefit over myelography.

RE: Referral under some Insurers. Is it appropriate?

Bob Russell — Fri, 09 Oct 2015 11:28:02 GMT

As I read RSA's statement they have gone ahead with everything they planned to do. The BVA statement seems to suggest that some agreement has been reached. To me it looks as if agreement has been reached for RSA to do what they planned to do.

I may be missing something but I am far from convinced that the discussion has done any good at all.

RE: Referral under some Insurers. Is it appropriate?

Francisco Gomez — Fri, 09 Oct 2015 11:19:04 GMT

[quote user="Braden Collins"]

I think this is not quite as black and white as it may seem at first. [/quote]

I see what you say, it is the approach what it gives things away a little.

As far as I know, Recognised RCVS Specialists hadn't been contacted by them, and the clients hadn't been informed about reducing/making it more expensive to access them. (Happy to be corrected about these statements, this is only what I see and know).

It is also important to point out that reducing this access to higher lever of expertise is not always a way of saving costs to be honest. Today I explained to a client that admitting their dog for a 'series of xrays under GA' might be a waste of money if we suspect the problem is spinal. Instead, use your money towards referral to RCVS recognised Specialist where they could also perform MRI/CT.

RE: Referral under some Insurers. Is it appropriate?

Braden Collins — Fri, 09 Oct 2015 10:04:11 GMT

I think this is not quite as black and white as it may seem at first. True, clients should have the right to choose within reason which vets they use. It is surely understandabe that insurance companies need to limit costs at some point. For example, I saw a TV progam once with a supervet sort of character. the dog had a hind leg lameness and was pretty much jumping up and down screeming cruciate. The vet on the show explained it was "crucial" to have an MRI to see what was happening in the joint. An extra how many hunderd/thousand pounds would have been added to the bill for a diagnosis a new grad could make on a thorough clinical exam.

Some people will argue that his treatment was goldstandard, but how many vets really feel that sort of work-up is justifiable? Surely the people who end up paying the bill (insurance companies) have some right to say "that's beyond reasonable".

In Australia, private health insurance is a way of life. It has created a 2-teir health care system but the government has set it up so the tax implications are that anyone earning a decent wage has to get private health insurance or pay a higher tax rate. Each specialist will provide there service for a set fee to the insurance company - it is negotiated at the start of each year. If someone wants to see a specialist who charges more and isn't in agreement with the insurance company (note: these specialists are independant), they will need to pay a gap.

I think the future will also see insurance compaies employing vets or similar to really assess claims and they will start declining what they see as unnecessary work-up steps.

Maybe vets in the UK who have been doing unnecessary blood tests (think 18month old healthy dog needing a stitch up having pre-anaesthetic bloods), advanced imaging when it's not really needed, and other such procedures which may boost profits have simply killed the golden goose and now everyone is going to feel the squeeze.

RE: Referral under some Insurers. Is it appropriate?

Hannah Wynne Richards — Fri, 09 Oct 2015 09:47:26 GMT

This is an intolerable infringement of an owner's right to chose, and a veterinary surgeon's clinical freedom.

Wynne

RE: Referral under some Insurers. Is it appropriate?

Francisco Gomez — Fri, 09 Oct 2015 09:27:17 GMT

[quote user="Arlo Guthrie"]

Another update: http://www.vetsurgeon.org/news/b/veterinary_news/archive/2015/10/08/139699.aspx#.VhbF8hNVhBc

[/quote]

Thank you Arlo...

Are we thinking things are shaping just the way we thought they would...?

Jun '15:

[quote user="Francisco Gomez"]

Is anyone not thinking that the most likely end scenario is that the RCVS will be happy with their statement and will stop there (We are not happy), the RSA will continue with their decision (We're doing what we planned anyway) and the first opinion vet will be left to pick up the pieces (and the non-preferential referral vets will lose business)

[/quote]

... hoping for the RCVS to fight it back ;-)

RE: Referral under some Insurers. Is it appropriate?

Arlo Guthrie — Thu, 08 Oct 2015 20:37:56 GMT

Another update: http://www.vetsurgeon.org/news/b/veterinary_news/archive/2015/10/08/139699.aspx#.VhbF8hNVhBc

RE: Referral under some Insurers. Is it appropriate?

Andrew Kent — Thu, 16 Jul 2015 18:19:34 GMT

Thanks for the update Ian, much appreciated.

Andy

RE: Referral under some Insurers. Is it appropriate?

Hannah Wynne Richards — Thu, 16 Jul 2015 17:58:32 GMT

Thanks Well done Royal College

Wynne

RE: Referral under some Insurers. Is it appropriate?

Ian Holloway — Thu, 16 Jul 2015 17:29:27 GMT

We held a meeting with representatives of RSA Insurance Group today to hear more about their proposed changes to their pet insurance policies, and to discuss the issues we raised about these proposals in our statement of 4 June 2015.

RSA agreed to consider these issues further, and said they would let us know by 22 July 2015 when they expect to be able to respond to these issues in detail.

Ian

Re: Referral under some Insurers. Is it appropriate?

Ian Holloway — Wed, 01 Jul 2015 15:47:36 GMT

A quick update...our scheduled meeting with RSA Insurance Group in June to discuss our stated issues about their pet insurance proposals was postponed at RSA’s request. Together with RSA, we're now seeking an alternative July date for this meeting.

I'll continue to keep you posted.

Ian

Re: Referral under some Insurers. Is it appropriate?

Arlo Guthrie — Thu, 18 Jun 2015 18:50:16 GMT

Latest news: http://www.vetsurgeon.org/blogs/veterinary_news/archive/2015/06/18/138407.aspx

Re: Referral under some Insurers. Is it appropriate?

Gillian Mostyn — Tue, 16 Jun 2015 15:04:54 GMT

Re: Referral under some Insurers. Is it appropriate?

J G Wray — Thu, 11 Jun 2015 15:38:36 GMT

[quote user="Francisco Gomez"]Except they intentionally sent a 'Private and Confidential' letter to vet practices so they can let us know what they expect from us BUT decided to inform their clients to a much lesser extent, so the pet owners don't cancel their insurance, instead s**t hits the fan when they are trapped... and it's backfiring.[/quote]

Well, one thing's for sure we're not here to police the insurance industry, nor for that matter are we here to act on behalf of our owners in a contract which exists between them and their choice of insurers. We are entitled not to get involved in that and tell our owners as much. Standing apart from this allows a cool head and some objectivity. Catastrophising this viz "...s**t hits the fan when they are trapped... and it's backfiring...."

ain't gonna help.

Looking at RSA's actions from the client's point of view it is difficult to appreciate loss if the patient never needs a commoditised referral service. Under these circumstances any measures to keep premiums down looks like good news, a gain for the customer/client. No client wishes to invoke a rainy-day exercise like an insurance because it means, to state the bleedin' obvious, that something's wrong with their animal and I haven't yet.met an owner wishing problems on their pet So, an insurance company conscientiously seeking all ways to control the cost of something an owner never wishes to use looks reasonable.

For the owner whose pet does need a commoditised referral service, there will be a standard experience or a loss to a degree. The standard experience will happen to those who live near the approved referral centre, because some policy holders must live near them. For others, there will be a loss through personal cost travelling/organisational difficulties etc, but, if you cast your mind back a few years, before taking some peculiar high ground, you may recall a time with fewer referral centres. Vets and clients had no problems rationalising travel etc when there was less choice.

If freedom of choice on where to go for something that might never happen, for price £X is evaluated by a client vs a restriction of choice for £Y, where Y is less than X, for something that might never happen, then RSA's condition, given that was how things used to be, doesn't look so bad. For clients that need this service, and clients aren't stoopid, there's an acceptance of the condition.

For those who don't understand the restriction, the vet is entitled to step back and refer them back to their policy. After all, there's time because these are not emergency cases. If, as a vet, you take on client obligation and fuel their uncertainty when the news of the necessity of referral is broached, by telling them of how their policy has shortcomings, you will create a rod for your own back. You, as a vet, will also creep into areas of insurance related behaviours their regulatory authorities exclude you from. Look after yourself, push the problem back to the owners and their insurance companies and look after the patient to the best of your ability under the circumstances - and chill.

Re: Referral under some Insurers. Is it appropriate?

Francisco Gomez — Thu, 11 Jun 2015 12:50:16 GMT

[quote user="J G Wray"]

RSA .. see themselves as providing a service for a price to the public which is derived from costs in this protected market, rather than as it should be with a more normal competitive market.

[/quote]

Except they intentionally sent a 'Private and Confidential' letter to vet practices so they can let us know what they expect from us BUT decided to inform their clients to a much lesser extent, so the pet owners don't cancel their insurance, instead s**t hits the fan when they are trapped... and it's backfiring.

I'm not against what they put in their contract. That's their business.

What is unacceptable is that people like Bob Russell found their change in his insurance through the 'Private' letter to his business, when he should've found it through a letter to him. With the same, or even more, ornaments and decorations that the first letter. At the end of the day, Bob (and sorry to use you as an example here) is (or was) a client of RSA, not the vet that treats Bob's pets!

Re: Referral under some Insurers. Is it appropriate?

J G Wray — Thu, 11 Jun 2015 12:32:11 GMT

RSA like the other insurance companies see a market with relatively little penetration of product, where the subject of the policy is a family member and family spend lies almost in the non-discretionary area.

Now that they're committed they are looking to increase profitability. There may also be a bit of insurance industry ideology at play here in so far as they see a sector, the veterinary sector, with a protected status, with a relatively low level of benchmarking and transparency in respect of services provided. This is a bit of a red rag, because they too are not completely venal and see themselves as providing a service for a price to the public which is derived from costs in this protected market, rather than as it should be with a more normal competitive market. They don't see market forces at play here as they are in other industries, notably the private medical and dental markets.

RSA will have a choice. They can retract their comments, or they can issue a modified version, or they can dig their heels in, start a meeja PR exercise for their point of view and look for support from other inscos. This is not a battle of right and wrong, with referral vets in the right and RSA in the wrong, Referral vets are simply not well enough organised, co-operative or benchmarked to defend their position over charges for commoditised services for long. Furthermore, if the inscos can make the case for there being a public interest in bench-marking and transparency from referral practices, RCVS will retreat into its bunker.

What have insured clients to gain or lose?

Re: Referral under some Insurers. Is it appropriate?

J G Wray — Thu, 11 Jun 2015 07:31:00 GMT

It's interesting me to look at this in a way that sees who gains and who loses from insurance policies that are worked in a way where non urgent cases with a predetermined course, even with a diagnosis from GPvets are handled in the "RSA way"

These cases are bread and butter for referral practices. They are cashflow. it is profoundly in their interest to maintain these at a certain level to ensure that fixed costs are met each month. Their business model is built upon the continued existence of insured patients and any pressures to reduce the price of these commoditised services will Hurt. Principles ain't got nuffink to do wiv it. It serves these practices to marshall all forces to their cause, clouding the issue with examples of complex medical cases, outside the remit here and claim support for "principles" of supporting the highest levels of recognised knowledge and freedom of clinical choice. These arguments are plausible, but incomplete. There's self-interest here and some honesty in this respect should be forthcoming at some point. It hasn't been up to now.

Just sayin' is all

Next, what's RSA to gain or lose....