MAINTENANCE – From June 1, injections to relieve pain from osteoarthritis of the knee will no longer be reimbursed. An unfair decision for rheumatologists.
New step in the de-reimbursement of osteoarthritis treatments. The Ministry of Health published a decree in the Official Journal putting an end to the reimbursement of intra-articular injections of hyaluronic acid from the 1er next june. So to alleviate their arthritis pain, patients will have to pay out of pocket for the product and the injections performed by the rheumatologist. This measure, criticized by specialists and patients, should allow Health Insurance more than 68 million euros per year.
To doctors, the ministry reminds that a medicinal version of hyaluronic acid can be used as an alternative. Dr Emmanuel Maheu, rheumatologist at Saint-Antoine hospital (Paris), has just co-signed an open letter to the Minister of Health, Marisol Touraine.
Why is this delisting decision unjustified, in your opinion?
Emmanuel Maheu: No, it is not justified. If we look at the most recent data in the scientific literature, hyaluronic acids appear to be the options offering the best risk / benefit ratios in the treatment of osteoarthritis of the knee compared to non-steroidal anti-inflammatory drugs or paracetamol. And they are on a par with corticosteroid infiltrations which do not have the same indications since they are reserved for inflammatory outbreaks of osteoarthritis.
We have a therapeutic option that has a small but very real effect. An effect that is found with all treatments in osteoarthritis. There is no one treatment that has a radical effect in osteoarthritis. So, this is very bad news for the doctors called on to medically manage osteoarthritis of the knee and the patients for whom these injections represented a therapeutic option allowing them to stay several months, even several years, without suffering and without seeing. need to see the surgeon.
Find the full interview with Dr Emmanuel Maheu:
Is there an alternative to these hyaluronic acid injections?
Emmanuel Maheu: Slow-acting symptomatic anti-arthritis drugs were discontinued almost two years ago. Hyaluronic acids will be from 1er June. The remaining treatment options are physical exercise, but when your knee hurts, going for a walk or cycling or jogging is not possible. It is therefore first necessary to relieve the pain and functional discomfort. And for that the only alternatives we currently have are opioids and nonsteroidal anti-inflammatory drugs. The latter are much more poorly tolerated and the benefit / risk ratios are much less good than hyaluronic acid.
Opioids in the elderly induce confusion and kidney problems, promote fall which is a source of fractures. And nonsteroidal anti-inflammatory drugs not only give gastrointestinal effects which all patients experience, but also cardiovascular and renal effects which can be extremely serious, especially in the elderly.
The Ministry of Health assures that a drug based on hyaluronic acid can be an alternative?
Emmanuel Maheu: The ministry has been practicing smoking for years. It consists of saying that access to this treatment is not prohibited since there is still a drug called Hyalgan. We therefore found ourselves with an absurd paradox: on the one hand we have a drug and on the other medical devices with different reimbursement rates even though they are equivalent. There is therefore no reason to keep the medicine, and not the devices.
And apart from the fact that it is reimbursed at 15%, most mutuals do not cover the remainder. It is obvious that not all patients will opt for this therapeutic option. The only good news in this catastrophic landscape is that the act of injecting Hyalgan remains reimbursed. While for medical devices that are delisted, the act will no longer be. Patients will therefore have to pay for the product and the procedures.
Will this reimbursement promote the use of total knee replacement?
Emmanuel Maheu: People who will have the money will continue to benefit from this treatment by paying full price or by paying packages. There is going to be a whole market. It will be anything to access care. The 9 or 10 million people below the poverty line will no longer have access to this treatment. From there we will have the possibility either of not offering them anything because they will not come to the doctor, or of prescribing them opioids or anti-inflammatories with their poor tolerance, the adverse effects and the fact that we cannot give it continuously.
So inevitably, patients, especially the less fortunate, will ask for surgery quickly. Their hospitalization and intervention being covered if there are no excess fees. These patients will end up with a prosthesis younger than today. The problem is, these prostheses don’t age as well as the hip one. And in addition, by placing prostheses earlier, they will have to be taken back more often. However, we do not know what results from frequent revisions of knee prostheses. In addition, between 20 and 25% of patients were not very satisfied with their prosthesis.
From an economic point of view this is catastrophic. Hyaluronic acid injections cost social security 120 euros per year, or 10 euros per month and per patient. The prosthesis costs 11,000 euros when it goes well.
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