Is Your Doctor’s Practice Patient or Insurance Focused?

Published on Aug 20, 2022

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I like writing about what I experience on a day-to-day basis. This morning there’s a nice debate on one of my Linkedin posts on the two different practice models that have been evolving: insurance versus patient-focused care. Hence, let’s dive into this issue this morning.

The Problem

I see patients all day every day who have been treated in insurance-focused practices. For example, a neck pain patient who has gotten radiofrequency ablation (RFA) of the painful facet joints three times and is now much, much worse when the RFA wears off. Or the low back pain patient with disc bulges and stenosis who has gotten a huge hunk of metal placed between the spinous processes (interspinous spacer) which destroyed huge amounts of normal tissue and now must get a fusion as their next step. Or the patient with headaches who has been treated with neck and head botox injections, even though we know that this will slowly negatively impact normal muscle function. Or finally, my favorite, high-dose corticosteroid injected into arthritic joints that we know will destroy their joint further.

What’s the problem with all of this? These are not the best most elegant solutions possible to treat these problems, they are what’s covered by the insurance company. In all of these clinical scenarios, the insurance-covered treatment causes harm to the body and the musculoskeletal system.

Patients rarely realize how insurance coverage and payment practices dramatically alter the care they receive or are offered. For example, we know that low back fusion for back pain is a really bad idea for most patients. We know that it works no better than just the standard back surgery and is associated with more patient harm and long-term problems like adjacent segment disease. However, it’s wildly popular and the number one surgery offered in the US because it pays the surgeon much more per unit time, and the company that makes the screws and bolts can sell fancy hardware store parts at a HUGE mark-up that would make most US defense contractors blush.

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Insurance vs. Patient-Centered Care

What is the defining characteristic of an insurance-focused practice? The main focus is only on offering care that is covered by insurance, even if that care option is not the best for the patient. There is also no discussion of cost, as a third party is paying the bill. Finally, the risks of various procedures are usually not discussed or downplayed. Hence, the “customer” in these practices is the insurer first and the patient second.

Is there a different way to run a medical practice? Yes, we began that journey in 2005 by placing the patient’s needs at the center of the practice. Hence, all treatment options are offered to the patient and the cost of each is part of the conversation because the patient is paying the bill. In addition, the risk-benefit of each treatment is discussed in detail.

Now, let’s explore a single medical condition and how that’s approached by both types of practices. A patient walks in with mild knee arthritis:

Insurance Model — Inject high-dose steroid into the joint. This will reduce pain, but will also begin to further destroy joint cartilage and increase the infection risk if the patient eventually needs a knee replacement. However, this deleterious treatment is offered because it’s covered by the insurance carrier.
Patient Model — Inject high-dose platelet-rich plasma into the joint because the totality of the research shows this is a better option for the patient that may help the joint long-term.

Hence, in the insurance model, the best treatment for this patient is usually not offered.

The Challenges of Running a Patient-Centered Practice

Why wouldn’t physicians be flocking to start patient-centered practices? On the one hand, there is a patient-centered trend, but while that movement has accelerated, the number of insurance-driven practices still dwarfs the number of patient-driven ones. Why?

Patient-centered means that oftentimes the patient pays the bill to get better care. That means that these practices tend to work better in places where patients have disposable income that they are happy to spend to get higher-quality care. They tend not to work well in parts of the country with minimal disposable income.

There’s a second HUGE barrier to patient-centered practices called hospital monopolies. Physicians are increasingly allowing large hospital groups to buy their practices. These hospitals incentive the care that’s covered and that pays the most money back into the system. So the low back patient will be offered steroid injections and/or RFA that can be performed in the hospital-owned surgery center. If that doesn’t work, a fusion performed in the same hospital-owned surgery center is the next step. It’s very hard, once you’ve allowed your practice to be bought by a hospital system to begin offering patient-centered care.

Threading the Needle

Is there a hybrid approach in orthobiologics? What I mean is can a physician both sleep at night because they know they are offering the best option for the patient and take some insurance? Can practices that are located in parts of the country where patients have less disposable income still do what’s best for the patient? That’s what we have created at Regenexx. With more than 600 employers contracted and our team adding new companies every day, a provider can now offer insurance-covered orthobiologics like PRP and BMC. Meaning that they can offer the best option for the patient without having to rely on treatments that harm the patient just because they’re covered.

In addition, this is a win-win for the company that’s paying the bill. How does work? By moving patients from the surgical column into the interventional orthobiologics column, the employer reduces their spending on orthopedic diagnoses and reduces lost time from work.

Corruption of the Patient-Centered Model

Is there a downside to the patient-centered model? There’s always an upside and downside to everything. The problem we’ve seen in patient-driven practices is the tendency for physicians to offer more expensive options to patients because they know they will pay. Just yesterday I dealt with this issue twice while on telemedicine evaluations with patients.

Two patients asked me why I was recommending a platelet-based injection in their neck and not “stem cells” (bone marrow concentrate). My answer was simple, it’s my job to recommend the least invasive, least expensive option that was the most likely to work. In their cases, that was platelets and not bone marrow. I did admit that if I had only offered bone marrow that would have doubled my income from each procedure, but that’s not how we roll.

Regrettably, in some patient-centered practices, you don’t see that type of restraint. Take for example my review of a chain of practices called “QC Kinetix”. These are practices that use a professional salesperson after a mid-level (not a doctor) performs a history and exam and fills out a form. The goal of the commissioned salesperson is to “up-sell”, meaning get the patient into the most expensive option possible.

Advice for Patients

How do you know which type of practice you’re in? High-quality patient-driven practices do the following:

Discuss ALL treatment options-both covered and not covered by your insurer.
Discuss how much each treatment will cost you.
The risk and benefits of each treatment are openly discussed.
NEVER use professional salespeople to upsell you. The treatment is decided strictly by medical need and not what you’re willing to pay. There is a discussion between you and the physician specialist and not a salesperson.

On the other hand, insurance-driven practices do the following:

Only discuss treatment options that are covered by your carrier.
Usually do not discuss the price of each treatment as that’s hidden (until you get the out-of-network bills later on from your carrier).
The risks of various treatments are usually not discussed in detail.

Obviously, if you can afford it, you want to be in a practice that is focused on your needs and puts those front and center. Or you need to have a forward-thinking insurer who realizes that offering interventional orthobiologics saves them money.

The upshot? Finding the highest quality healthcare possible is a HUGE task these days. Patients not only need to educate themselves on what’s wrong and what might help, but they also need to gravitate toward medical practices that place them at the heart of the discussion of which treatment might be the best fit.