Three Common Financial Misconceptions in the Medical World

Understanding the complexity of various medical expenses can be overwhelming for a patient. We medical professionals are patients too! Even for us, sometimes the numbers just don’t make sense. At Impact Sports Medicine and Orthopedics, our desire is to educate patients regarding the value of these office visits and procedures and their potential out-of-pocket costs, so that they can make informed decisions regarding their health care from both a medical and economic perspective.

Here are three common misconceptions when it comes to medical expenses:

1. If my physician is not in-network with my insurance company, my medical expenses will be higher: until patients meet their deductibles, they typically will pay out-of-pocket for office visits, diagnostic tests and procedures. The amount a patient pays can also depend on a patient’s out-of-network provisions in their plan and/or the amount an out-of-network provider chooses to bill the patient. Often an out-of-network provider will ask the patient to pay cash, and this amount can be and often is less than the contracted amount an in-network provider has with your insurance. Example: you have Insurance X, a plan that has accepted very few in-network physicians. You have not met your deductible and you see an in-network orthopedic specialist for a consult. You have an office visit and x-rays. Insurance X allows $150 for the office visit and $50 for the x-rays. You now owe that in-network physician $200. Alternatively, you see a provider at our practice as we are in-network with most insurance plans, but not with Insurance X. We charge you $120 for the office visit and $30 for x-rays. Thus, your bill with us is $150, a $50 savings compared to the in-network provider.

2. If a procedure is not covered by insurance, it will cost me more in the long run: as an example, let’s use a procedure such as a platelet-rich plasma (PRP) injection. PRP has been used in orthopedics for 15 years. It has never been covered by insurance (although it should be in certain circumstances…that’s a whole different conversation). You have stubborn plantar fasciitis. You’ve done all the typical treatments, but your heel still really hurts. You consult with a foot surgeon who offers an open or endoscopic plantar fascia release surgery. Guess what, your insurance covers this procedure! However, you have a $5000 deductible, and you are nowhere near meeting this. This surgery will have charges from the surgery center, the anesthesiologist and the foot surgeon. Let’s say that your total cost for this surgery is $3000 with a 75% success rate, a 4-month recovery and some risk of additional complications. Compare this to one or two PRP injections, with each injection costing you $800. PRP, in our opinion, will have similar success rates and recovery times with fewer complications. $1600 for PRP versus $3000 for the surgery, even though the surgery is “covered by insurance.”

3. When it comes to an office visit or the same procedure done at different practices, insurance companies pay or allow the same amount for each physician/practice: did you know that all practices, hospitals and other medical businesses have contracted rates of payments with private insurers (non-Medicare, non-Medicaid)? If a physician is part of a bigger organization such as a hospital or a large private practice, then that group typically has greater negotiating power and can obtain higher reimbursement rates from the insurance companies. These rates have nothing to do with the quality of medical care, the training or experience level of the providers or the success rates of their interventions. So, let’s say you see a physician associated with a hospital system. You haven’t met the deductible, and you are billed for a Level 4 new patient visit. Your insurance allows $200 for that visit to that provider. Alternately, your household family member sees a physician at a smaller practice like ours, also is billed for a Level 4 new patient visit, yet the same insurance only allows for $150 for that visit, even though the same level of care was provided. So, you owe $50 more to that hospital-based practice than your family member owes to the smaller private practice. Thus, it’s important to realize that often cost really does vary based on who you are seeing, and your cost is not associated with the quality of the care.

   At Impact Sports Medicine, cost education and financial transparency are very important to the physician-patient relationship. We strive to provide the highest quality of care for a reasonable out-of-pocket cost to you.

   F. Clarke Holmes, M.D.

The Dirty Little Secrets Some Chiropractors Aren’t Telling You About Stem Cell Injections

“Judy,” our middle-aged patient, presents to our practice with chronic knee pain due to arthritis. She is seeking another opinion. She relates that three months ago she went to a “Dr. X’s” chiropractic office seeking the miracle cure of her chronically painful knee. She had seen a Facebook post from the chiropractor’s office advertising “stem cell” injections for patients with painful orthopedic conditions. The ad looked great. The testimonials on the website captured her even more. After two previous knee arthroscopies (“scope surgeries”), this was now her chance to get that knee better without a knee replacement. Per the advertisement, “regrow cartilage and become pain-free, all with just a simple injection.” She placed the phone call and within a week, she was in “Dr. X’s” office writing that rather large check to receive her miracle shot of stem cells. Fast forward 3 months and now “Judy” has paid $5000 out-of-pocket for her pseudo stem cell injection and another $1000 for a knee brace. It’s obscene. Has she seen improvement? A “little bit” she tells us, but not enough to justify that $6000 check.

Concerned. Disappointed. Angry. Those are the first words that come to mind when I read or hear about another non-medical doctor advertising “regenerative” injections, such as stem cell or platelet-rich plasma. I’ll be honest here…the greatest number of advertisements come from the practices of chiropractors. Here’s the irony: chiropractors cannot legally give orthopedic-based injections. So, what’s the catch? Most hire mid-level providers, physician assistants (PAs) or nurse practitioners (NPs), to give these injections. Mid-levels serve very valuable roles in our healthcare system. Some are skilled enough to provide injections in a very competent fashion. However, our medical system has been designed such that mid-levels are mentored and directly supervised by medical doctors who have expertise in providing procedures such as injections. In the case of a chiropractor’s office, how can the supervising chiropractor mentor or teach the mid-level to do an injection when he or she has never given a joint, tendon or other similar injection in his or her entire career? It just does not make sense, plain and simple. Then, you are talking about very advanced injections, most of which are not covered by insurance and cost the patient hundreds to thousands of dollars. Finally, many of these injections done by mid-levels are not guided in any fashion, meaning neither ultrasound nor fluoroscopy (live x-ray) is used. Thus, the accuracy of the injection is likely less than optimal.

Here's another valuable piece of information: these injections claiming to be “stem cell” injections very likely have minimal to zero live stem cells. Most independent studies have verified this. Most of these injections primarily consist of amniotic fluid, the fluid surrounding a fetus when a woman is pregnant. Now, amniotic fluid does have value, as it is rich in growth factors. These growth factors can serve to reduce inflammation, and thus, lead to a reduction in pain and improvement in function. Can they help cartilage to regrow? The truth is that we don’t know. Right now, it’s unlikely that any injection can reliably regrow cartilage, so the honest clinician tells the patient that although cartilage regrowth is theoretically possible and may occur in some cases, we certainly cannot guarantee this will happen. So, when a medical practice is using an injection such as this that does not come from the patient’s own fat/adipose or bone marrow, then it is not a true stem cell injection. Thus, the claim that “stem cell” injections are being given is misleading at best, fraudulent at worst.

Quickly, we will also cover the cost of these injections. Admittedly, some of these best procedures in orthopedics are not covered by insurance. Thus, medical practices can set their own prices for these orthobiologic injections. What’s reasonable to charge? On top of the cost of injection and materials to provide the injection, add in the typical cost of an office visit, the cost of the injection procedure, ultrasound guidance (if used) and for the time/research it has taken to develop an expertise in this skill. What’s that worth? $300-$500 is our typical “mark-up” a for platelet-rich plasma or an amniotic fluid injection. We believe this is very reasonable and equal to or less than most of our peers who are experts in providing orthobiologic injections. When a patient pays $3000-$5000 out-of-pocket for an injection (other than a true stem cell injection), then you can bet that the mark-up is in the thousands, not hundreds. Once again, it is so disheartening that some medical practices decide to take advantage of patients desperately seeking relief from their painful orthopedic condition.

Here’s the bottom line: even with all the radio, magazine, TV and social media advertising done by some practices claiming to be experts in “regenerative injections,” you need to carefully choose who you want to provide these advanced office procedures. I have a very healthy respect for several of my colleagues who are chiropractors. I freely refer to them. Many do an excellent job with care of the spine and rehabilitation of some extremity issues as well. However, orthopedic injections are just not in their wheelhouse.

At Impact Sports Medicine and Orthopedics, we have used ultrasound guidance for 11 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to orthobiologic/regenerative injections and have provided these to our patients over the past 9 years. We are not the only ones in the Nashville area doing these advanced injections, but you will be hard-pressed to find any practice more experienced or dedicated to the honesty and integrity of the process.

-F. Clarke Holmes, M.D.