Regenerative Medicine vs. Health Insurance

Regenerative Medicine vs. TKA

Why Insurance Won’t Pay for Orthobiologics

S. Austin Yeargan III, MD

We really are a “Regenerative Medicine” Clinic and that’s why we were the first in the country to arrive at the conclusion that the name “Regenerative Medicine” would be ideal for our practice.

To this day, there is no clinic in the United States, or the rest of the world that does what we do. While many copycat type clinics have sprung up all over the country, most are using our first and second-generation techniques. Currently, we’re on our seventh and most advanced signaling cell treatment yet.

All of our procedures, including our flagship Nanoplasty or “NAMAD†” procedure are based on our own intellectual property that we’ve been developing since 1997 when we began our early work with platelet rich plasma. While extensive study of the growth factors contained in dense granules appeared to be the holy grail and hold infinite promises, it turned out to be a different adventure than any of us had in mind at the time. Even today, PRP struggles for any meaningful clinical application and most studies have shown it to be at least as detrimental as helpful, even when cost is excluded from the equation.

Seizing on our work, just like today, opportunists in pain medicine tried to copy our ‘appearance’ and use the same language we did. The result was widespread patient exploitation, distrust of doctors who it turned out were making false claims of expertise, and mostly treatment failures. Recently an article in the Journal of Bone and Joint Surgery from the Langone Medical Center in NYC pointed out that 96% of clinics that claim to offer what we do are misrepresenting themselves and their services. This problem continues and has escalated dramatically over the last decade since we introduced the techniques to the field.

The landscape has changed enormously over the last decade, but the same issues persist. This has left patients with more unanswered questions that providers offering ‘regenerative treatment’ or ‘orthopedic pain treatments’ who are not orthopedic surgeons have figured out tricky ways to lawyer their way around answering. When you rely on your insurance to pay for your healthcare, its in everyone’s best interest except yours to have surgery.

When you rely on cash services in pain clinics, it’s only in the best interest of the provider and the corporation they have teamed up with to trick you into thinking you are receiving a treatment that you are not. This is clear. The FDA has become wise to the myriad of fake regenerative products that are being advertised and sold to unassuming and miseducated patients around the globe.

We think that patients deserve to know and understand exactly what they are paying for and why they have to pay for it. They also deserve to know why it’s supposed to work and what happens if it doesn’t work and why. Patients deserve to know what is being put into their bodies and what the real risks of the services are.

Insurance companies do not cover the very expensive procedure that we offer, so we make sure the patients we indicate are going to have a successful result. It’s easy for an orthopedic surgeon to indicate a patient with knee pain for a total knee replacement. There is no mandated work up and most surgeons don’t even template patient radiographs for the implants. With at least 20% of patients in all global registries clearly dissatisfied with knee replacement surgery, it’s probably an important step that’s still necessary and the impetus for the introduction of robotic technology into orthopedic surgery.

Why don’t insurance companies pay for your procedure?”, is a common question I hear every day. To understand why this remains so, imagine you are in business, which doesn’t have anything to with patients. The CEO of that business gets paid bonuses and gets to keep his job as long as the insurance company is making money, a lot of money. To ensure that he keeps his job and makes as much money as he can, he focuses on the imperative: show profit gains no matter what the cost. Patients are lost in the shuffle. Your health insurance covers the BASICS. Need more than the basics? Your health insurance covers the minimum, not the best. This is evident in all fields of medicine, not just orthopedics. In the event of knee pain that “doesn’t respond” to conventional paid-for treatments, guess what? You’re a candidate for a total knee.

“Halleluia!” gleems your insurance agent. You just made their day.

When you settle for a knee replacement because your insurance doctor recommended it, it’s in everyone’s best interest but yours. (What! My insurance company doesn’t care about me!?)

When you sacrifice your knee joint, let’s hope you REALLY tried everything else first. Once you sign up and have the extensive surgical procedure, you can realistically count on 6 weeks to 6 months before you’re not angry at your surgeon and have stopped wondering why you EVER agreed to this. One out of five patients won’t even be happy by 5 years, in fact, they remain dissatisfied for the rest of their lives.

What happens if you don’t have a good result following the Nanoplasty, or NAMAD†? Nothing. Your investment and hope of avoiding knee surgery may be spent, but you’ve still made significant gains that ensure that when you DO need a knee replacement, you’re in the best shape possible for it. In all honesty, the nanoplasty, or NAMAD† is ideal for anyone with unicompartmentl arthrtits and using our algorithm following our unique concept of arthritis, the procedure can last your lifetime.

In patients who aren’t ideal candidates, meaning patients who do not meet our inclusion criteria and who we think are less likely to be able to expect a lifetime of pain free activity after NAMAD†, pain relief is still excellent, it just only lasts for about 2-5 years and that’s been pretty consistent over the last decade. If you are not happy with your NAMAD® result, which is rare (over 95% success rate in avoiding total knee replacement for a minimum of two years) Your tissues are in the best condition they have been in and your entire body is far more prepared when it comes time for replacement of your knee joint with metal and plastic. Sometimes that’s just the best solution. If it is when you first present to us, we’re going to tell you that up front. Can I have my knee replaced my any orthopedic surgeon? Not advisable.

Multiple studies have shown that the better the training and the higher the volume, the better the outcome in total knee replacement. With a 20% dissatisfaction rate, no matter where you look up objective scientific results in any global registry, it’s in your best interest to find the best surgeon you can. Don’t be talked in to convenient options, they almost never pay off. There are plenty of ways to arrange to have your knee replaced next week by the best surgeons in the United States and the world. That’s inconvenient for average surgeons living in average communities. They prefer a captive audience without options. I always recommended three different opinions from different entities when considering joint replacement surgery.

Now that it’s become clear as day that we were right over the last decade of name-calling and jeering, peers and colleagues have done their best to imitate what we’ve done-and we appreciate that. It’s flatteing quite honestly. Sadly though, they still don’t like to send us patients for additional opinions for several reasons. The most common one is that there is the big risk that the consulted surgeon will see that they are indicating patients for a big surgery when it’s not indicated and economically they just don’t want to lose any surgeries from their docket. Depending on personality and referral patterns and whether the opinion comes from a MD in the same group, an objective third opinion will usually shore up the details and make the path more clear for the patient, which is what this is all about.

Author
S. Austin Yeargan III, MD Orthopedic Surgeon Molecular Immunobiologist

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