Are Ultrasound Guided Shoulder Injections Better?

[mtomaino]

This is a question of great debate. The reason why it is debated is that some people, including many insurers, feel that doctors only use these injections because they can submit a bill and capture a fee for this service. THIS IS A TRUE STATEMENT. Sadly, I saw a patient today who was going on vacation and went to see her Orthopaedic surgeon for a subacromial injection because of a flare up of bursitis. This is one of the easiest injections to perform, especially for a shoulder expert. However, he told her that the PA that uses the ultrasound machine was not there that day, and he, himself, refused to inject. WHY? Sadly, the answer is not that he was not capable of this injection without the ultrasound. Rather---it was to avoid missing out on the $350 or more fee for the ultrasound.
Ultrasound is quick and relatively easy, and aside from the initial cost of the machine, there is little ongoing cost to using this technology. Indeed, this patient shared with me that she received an actual bill for $1000 for the eventual injection. What is crazy is that this was paid by the insurer. What is sad is that the physician was more concerned about incremental reimbursement than about taking care of his patient. This is truly a money grab in many practices---and until the insurers appreciate the all too often lack of need for the technology, it will be paid for and utilized by unscrupulous, and I dare say, greed-driven practitioners.
Although, there are a number of studies that demonstrate improved accuracy of the ultrasound guided injections, they are often uncontrolled and biased—designed to support the underlying preference. Further, any Orthopaedic specialist is more than capable of simple subacromial injections, let alone injections into the glenohumeral joint. That having been said, if there is a justifiable indication it may be to ensure accurate needle placement for joint aspiration when one is ruling out infection, or to access more anatomically difficult, deep joints like the hip.
Here’s the problem---because this technology is being overused--- it will eventually be denied, or require a preapproval---even when justified. So as to avoid an unanticipated cost assignment, my best recommendation is to ask your doctor about whether it is necessary to use this technology for your injection. Nowadays it’s all about patient engagement. The days of “medical priesthood” whereby the doctors tells you the way it is without discussion should be long gone. If you are going to be responsible for some or all of the cost, you may want to ask how much difference the ultrasound is likely to make. Further, in addition, an ultrasound machine, like any medical technology, is only as good as the person using it. Appropriate training and experience are necessary to use this technology properly. Ask your doctor how long they have been using the technology and how they were trained to use it. This applies to the doctor’s PA (physician’s assistant) as well. It may be that you should search out a Specialist who is honest enough not to utilize this technology when it is unnecessary even though it might be reimbursed. In the final analysis, this will save you, the patient, real dollars and go a long way to building mutual trust!