Why isn’t Regenerative Medicine (Cellular Therapies) Covered by My Insurance Company?
In our Regenerative practice, we are repeatedly asked this question: “Why Aren’t Regenerative Medicine (Cellular Therapies) Covered by My Insurance?” The simplistic insurance company answer to this question is that these treatments are considered “experimental”. The word “experimental” raises concerns that the treatment is potentially harmful and/or has no proven benefit. Over the past decade there has been a great deal of research and publications noting first: the lack of any significant harmful effects from platelet-rich plasma (PRP) or “stem cell” treatments (Cellular Therapies). The concerns of these cells causing cancers or other disorders have been refuted now by several studies (Current Stem Cell Research & Therapy, OARSI Journal, International Orthopaedics) that have examined thousands of patients for many years. A physician’s first oath is “first Do No Harm” and we at New Jersey Regenerative Institute are confident that the treatments we are providing patients are safe AND EFFECTIVE.
The effectiveness of both bone marrow and adipose/fat in the treatment of cartilage damage has been demonstrated in multiple animal model studies and in humans. Patients should be aware that there are many aspects of providing PRP and/or cellular treatments that your treating doctor should be aware of and that you, as a patient, should ask your provider offering these treatments. As in any area of medicine it begins with selecting the right patient for the right treatment. This should include a detailed history, a comprehensive examination and the physician’s personal review of any testing you have had, especially x-rays and MRIs. The treatment that is offered should be INDIVIDUALIZED and COMPREHENSIVE and not the same treatment offered to anyone who walks through the door. If your doctor fails to do these simple things, then you should find someone else to care for you. The recommendations should provide you with a variety of treatment options and should be carefully reviewed with you. This is often NOT done in offices offering Cellular Therapies but even less commonly in current physician practices.
Patients often agree to these standard medical treatment recommendations because they are COVERED BY INSURANCE. Patients should be aware that MANY of the treatments that are COVERED often lack the level 1 evidence that the insurance carriers are requiring from Cellular Therapies to be covered. Many treatments that ARE COVERED have been noted to produce harmful effects. These include non-steroidal anti-inflammatory medications, cortisone injections, etc. Many of the recommended surgical procedures such as arthroscopic surgery for degenerative meniscal tears have been shown to be no better than physical therapy or even SHAME i.e. fake surgery. And yet, over 500,000 knee arthroscopic surgeries are performed each year at a cost of $7-9,000/per case including the facility fees. These treatments can also accelerate the degenerative process leading to the need for knee replacement surgery which is a fairly large surgery with surgical and post-operative risks and with some studies demonstrating that 20 % of patients STILL HAVE KNEE PAIN AFTER KNEE REPLACEMENT SURGERY! There are over 650,000 knee replacements performed in the US EACH YEAR and the group that is having their knees replaced at the fastest rising rate is between the ages of 40-50 years of age. Total knee replacement was not designed for this age group! Many knee replacements will begin to fail after approximately 20 years. This then requires REVISION KNEE REPLACEMENT, a much more difficult surgery with lower outcome results. Given that many of us will live into our 80s, if your knee is replaced sometime in your 40s you may need 2 ADDITIONAL knee replacement surgeries, each more difficult at ages where we develop several other medical issues which can further complicate things.
Beyond these many issues, one question to ask is “Why shouldn’t we pay for medical care?” We are all used to paying for dental services including major surgical procedures such as dental implants. Pet owners have no problem paying for various veterinary services for their pets including grooming, medications, surgery, etc. We have become accustomed to having insurance medical companies paying for nearly all medical care and assume that they will. Unfortunately, then they can decide what is “covered and not covered” what is “reasonable medical treatment” and thus what they will pay for. Health insurance is vital when we suffer major medical illness and trauma that can result in medical bills in the hundreds of thousands of dollars. It is probably best to think about how we use our auto insurance policies where everyday expenses and maintenance is paid by us and we have our auto insurance for accidents and other major damage to our cars. We don’t use auto insurance to pay for our gas, or new windshield wipers or if our breaks or tires wear out. Therefore, auto insurance is generally much more affordable than health insurance. But this could change if we use the same philosophy for health insurance. If we instead purchase health plans that will cover for major events such as accidents, cancer, heart attacks etc, and then use a health savings account to cover more common things such as x-rays, MRIs, doctor’s visits, minor surgery, etc (See “What can I do?) the costs of these plans would be greatly reduced. So instead of a family plan costing $20,000/year it could be reduced to $ 10,000/year and the savings INVESTED in a health savings account which is deducted PRETAX and can grow in interest if not used but ready to use as a health credit card for these common expenses. That then puts YOU in the driver seat of who you want to see and how you want to spend YOUR HEALTH care dollars!!!
Many people are becoming increasingly disappointed and dissatisfied with the health insurance coverage they have and the costs associated with their plans. A detailed article with many graphs was recently published by The Kaiser Family Foundation. This article reviews the many issues that have arisen since the Affordable Care Act (ACA) aka “ObamaCare” was implemented (signed into law in March 2010). The article notes: “In the current survey, about half (49 percent) of those with ACA-compliant non-group coverage say their plan has an annual individual deductible of at least $1,500 or a family deductible of at least $3,000, up from just over a third (36 percent) last year.” The survey found that “the share rating their coverage as “not so good” or “poor” is higher in 2016 (31 percent)” than it was in the two previous waves of the survey (20 percent in 2014 and 21 percent in 2015).” “Just over half (54 percent) now rate the value of their coverage as “only fair” or “poor” (up from 42 percent in 2015 and 39 percent in 2014).”
In addition, many of those surveyed reported problems with the plans: “Most commonly, just over a third (36 percent) say their plan paid less than they expected for a bill, about a quarter (26 percent) say their plan wouldn’t cover or required a very expensive copay for a drug prescribed by their doctor, one in five (21 percent) say they were surprised to find their plan wouldn’t pay anything for care they thought was covered, and a similar share (20 percent) say that a particular doctor they wanted to see wasn’t covered by their plan.
This data comes from the almost 13 million people signing up for plans through the ACA marketplace. These plans have been subsidized by HUNDREDS OF MILLION dollars from the Federal government i.e. OUR TAX DOLLARS! There are many more millions of people who purchase health care or have it as a benefit from their employer that must survive WITHOUT FEDERAL SUBSIDIES. The costs of these plans are even higher, with many people opting for plans with EVEN HIGHER DEDUCTIBLES and co-pays in order to afford a plan’s monthly premium. Even those with employer provided plans are now being asked to contribute more and more for their insurance plans.
Many doctors are concerned by the control of medicine by the Federal government e.g. Medicaid and Medicare; the health insurance industry and larger healthcare organizations that are “buying out” physician practices. Several doctors have made the bold decision to not follow the crowd and actually “opt-out” of Medicaid and Medicare and other insurance plans so they can provide the care to patients they feel is in their patients’ best interest. Others have offered affordable care with transparent costs like the Surgery Center of Oklahoma and CIAMPI Family Practice.
What You Can Do to Obtain Quality Healthcare
- Keep yourself healthy by eating right, exercising, reducing stress, getting enough sleep, etc. to avoid needing a doctor.
- Choose a plan that covers you for serious illness and injuries with a fairly high deductible (considered “catastrophic” coverage).
- Get a Health Savings Acount (HSA/HRA) that is a PRETAX benefit you can use to pay for things not covered or that you will need to pay prior to reaching your deductible.
- Shop around, find out the TRUE costs of medical services and negotiate based on your knowledge of the cost.
- Seek out care from medical providers who will spend time with you; will provide you with INDIVIDUALIZED care, who will AVOID treatments that may be harmful to you, who understand and consider costs (which they can discuss with you), and who have kept up with the medical literature and can provide the most advanced treatment options to you.
- Get informed and decide on the care that is in YOUR BEST INTEREST, not the insurance carrier, the doctor’s, pharmaceutical company, etc. interest. Pay for quality healthcare and get the best treatment for your medical condition. There is probably nothing more important to our lives than our health: “If you have your health, you have everything!”