Insurance Coverage vs. Treatment Results
What insurance pays for, and what treatment produces the best results for an individual patient, can be two very different things. More and more people are deciding that they are not going to let insurance coverage dictate their healthcare choices. For many, this means that they have to re-prioritize their finances. Many have found that living with the loss of quality of life and limitations isn’t worth staying in the insurance box. At Olympic Spine & Sports Therapy, we are proud to say that we work for you, not for the insurance companies. With that being said, we do work with nearly all major medical insurances. However, almost all of our patients’ treatment plans include therapies that are not covered by insurance. We want you to know upfront that you most likely will incur out-of-pocket expenses.
What to expect when you come to see us
Informing you upfront is an ideal that we carry through every step you experience in our office. It begins with a consultation that is provided at no charge.
- Consultation (no charge): to determine whether or not we think we can help you.
- Detailed examination and testing ($200 – $400): to determine if you are a candidate for treatment.
- Report of finding(s)(no charge): providing you are a candidate for treatment, we will create a detailed plan outlining what treatments you need, how long it will take, and how much it will cost.
Understanding Treatment Cost
Regarding treatment cost, of course, it depends on each individual’s condition, what treatment they need, and how quickly they respond. If your condition is relatively simple, sometimes a single type of treatment is sufficient. Chiropractic adjustments, high dose laser or massage therapy alone may do the trick. If your condition is more complex, it is likely that a combination of therapies will be necessary to get the best results. For complex conditions we typically offer two treatment options:
- Relief care (for symptom reduction)
- Relief and Rehabilitation (to reduce symptoms and correct the underlying cause)
- Disc herniation/degeneration
- Spinal stenosis
- Peripheral neuropathy
- Chronic joint pain (hip, knee, shoulder)
Relief care for chronic conditions generally involves treatment three times a week for four weeks and typically ranges between $2,000 – $4,000 for out-of-pocket-expense. Relief and rehabilitation treatment for chronic conditions generally requires a treatment frequency of three times a week for four weeks, then two times a week for four weeks, then once a week for four weeks. The out-of-pocket expense typically runs between $5,000 –$7,000.
We are solely committed to your care
We understand that providing this information upfront is not a good sales technique. But we are OK with that because our main goal is to provide the most effective treatment possible, not to get someone to sign up for care. Once we determine that a patient is a candidate for treatment, we want to make sure our treatment plan works for them in all respects. This includes finances, time, and effort. Finances are part of the picture, but not the whole picture. But before we look at some of the other pieces, let’s look at the numbers.
Is spinal surgery worth it?
According to the National Center for Health Statistics, 1.2 million spinal surgeries are performed nationally each year. The procedures that are the fastest-growing are lumbar spinal fusions that range from $60,000-$110,000 per procedure. It’s not uncommon to have patients agree that those procedures are very expensive, but say something like: “but my insurance will cover it.” We will look at what the out of pocket expense cost is. But before we do, there are two other concerns to factor in where surgery is concerned:
- What are the risks?
- Will it work?
Having the majority of the expense covered is great, but what if it doesn’t work, or worse yet, what if there are “complications”?
“Low-cost” back surgery
According to healthcare.gov, typical insurance plans have a deductible of $1,300 and coinsurance of 20%. For a plan like this, a “low-cost“ surgery like a cervical discectomy and fusion that costs $14,000 would result in an out-of-pocket expense of $3840.
“Higher cost” back surgery
For a “higher cost“ operation like a single level lumbar fusion that cost $26,000, the out-of-pocket expense would be $4400. Of course, multi-level fusion surgeries that are $60,000-$100,000 would likely have a much higher personal expense.
The hidden cost of back surgery
According to Dr. Scott Hodges, orthopedic spine surgeon: “less than a third of the money spent on fusions is for the procedure itself”. Back surgery patients also pay significantly for:
- Procedures before and after surgery: visits to other doctors and therapists, tests like MRI, EMG/NCV, treatments like injections or prescription medications.
- Time lost from work: often, patients are unable to work before surgery because of the pain. Following surgery, it’s not uncommon for patients to miss weeks or months of work during the recovery process. Low back pain is the leading cause of disability worldwide.
- Complications and additional surgery: according to a 2017 study published in the journal Spine, one out of five patients that have spine surgery are re-hospitalized within 30 days. Nearly 60% were emergency room visits, usually for infection and unmanageable pain. Over 26% of those patients ultimately were scheduled for an additional surgical procedure.
Now that we have looked at the numbers, let’s look at what a spinal surgery potentially can do for you, and what it can’t. The objective of decompression surgery is to reduce pressure on the nerves exiting from the spine. For a decompression and fusion surgery, in addition to reducing nerve pressure, one or more spinal joints are immobilized, typically using a plate and screws.
At best, this may reduce the patient’s symptoms. Surgery does not address what caused the condition in the first place. In the vast majority of cases, disc herniation/degeneration, stenosis, spondylolisthesis, and degenerative arthritis are caused by abnormal spinal mechanics. This includes altered posture, muscle imbalances, and impaired strength and stability.
Surgery does not address these underlying causes of degeneration and pain. If they’re not addressed, it’s likely that the pain will return. Rehabilitation to correct posture, normalize mechanics, and restore strength and stability can add thousands of dollars to the cost of surgery. More often than not, these rehabilitation procedures are skipped or addressed only at a superficial level. At Olympic Spine and Sports Therapy, we believe this is one of the main reasons that spine surgeries have such poor outcomes. According to a 2011 study published in the journal Spine, back surgeries have a failure rate of 74%.
Our stance on surgery
It may sound like we’re against all surgery – we want to be clear that we are not. Every year, there are a handful of patients that we refer for surgery. There is a time when surgery is a patient’s best option. If there is a tumor or compression to nerves producing a loss of bowel or bladder function, surgery is likely the best solution. However, according to current research, patients that suffer from chronic low back pain should seek non-surgical treatment alternatives first.
Surgery: All or Nothing
This brings up another problem with surgery, it’s all or nothing. You can’t “try a little of it” to see if it works for you. Once it’s done, it’s done. This also relates to our discussion about treatment costs. At Olympic Spine & Sports Therapy, our protocol is to use our comprehensive conservative treatment for one month and then re-examine the patient. This is the “go-no- go“ point. The patient must be able to report a marked improvement in their symptoms and objective testing has to back it up. If these goals are not met, treatment is not continued. With our conservative treatment approach, the patient is in control, visit to visit. They have the option of testing treatment with a trial phase of care, unlike surgery that is “all or nothing“.
Although we have focused on back pain, similar statements can be made for other chronic conditions like peripheral neuropathy and chronic joint pain. While surgery is not used as frequently for these conditions, the treatments that are recommended come with their own list of problems.
Chronic joint pain
Chronic joint pain is more likely to be treated with steroid injections and prescription medications for inflammation and pain. Steroid injections can dramatically reduce pain and inflammation. Unfortunately, for most chronic conditions, the pain returns.
Steroid Side effects
We believe this is similar to what we described earlier about low back pain returning after surgery. If the underlying cause has not been corrected, history is likely to repeat itself. In addition to offering limited relief, steroid injections can have the following side effects:
- Weaken tendons and ligaments.
- Suppress immune function
- Increase the risk of fracture
Conventional medical treatment for peripheral neuropathy usually includes medications like Gabapentin, Lyrica, Cymbalta or opioids like Tramadol or Oxycodone. Some of the side effects for these medications are as follows:
Medication Side Effects
- Blurred vision
- Impaired cognitive function
Most patients that come to us with peripheral neuropathy are looking for an alternative to these medications. The majority tell us the benefit they got from the medication wasn’t worth the price they paid with the side effects. Additionally, one of the greatest concerns patients with peripheral neuropathy have, is the progressive loss of their independent mobility. Having to rely on a cane is inconvenient, a walker has significant limitations and a wheelchair requires major lifestyle revisions.
While these medications may help to relieve the nerve pain, they can’t improve balance, stability or strength. In addition to pain relief, most patients that come to us with peripheral neuropathy are looking for ways to maintain their ability to do normal life activities. They don’t want to have to rely on using a cane, walker or wheelchair. This leads us to what may be the greatest cost of treatment, or cost of no-treatment. The cost of lost quality of life.
What about the cost of lost quality of life?
The financial costs we’ve discussed are easy to add up. The loss of quality of life is far harder to calculate. What dollar value do you place on:
- Suffering from chronic pain?
- Not being able to sleep soundly?
- Straining relationships because you are irritable and on edge?
- Not being able to do the activities you enjoy?
- Not being able to participate in social/family activities?
This patient’s story is a good example of the life quality costs.
I would’ve written a check for $100,000 if I had known I could get this much relief I haven’t slept for more than 2 ½ to 3 hours at a time in 10 years because of the pain. I tried medication, massage therapy, chiropractic, physical therapy, and injections. I am a small business owner; my plan is to retire in five years. My concern was retiring with constant pain, being limited in what I can do, and not being able to enjoy time with my family. The treatment is expensive, but honestly, I would’ve written a check for $100,000 if I had known I could get this much relief. My life is so much better. Now I can work a full day and sleep through the night! I rode a bike 20 miles and played softball with my kids. In addition to the treatment, it’s an education. I’ve learned how to sit and move properly. I always get an explanation to my questions, not a short “move along” answer. The staff is exceptional, they’re all invested in the patient’s results.
Often, patients pay the highest price in these non-monetary costs. Only you can set a dollar amount on your quality of life. As the saying goes: “you can’t take it with you!” Travis is one of the thousands of patients we have helped to experience less pain, have more mobility and reclaim activities in their life. We have helped them accomplish this without the use of drugs, injections or surgery.
Summary of hidden treatment costs:
- spine surgery: average out of pocket expense $4000
- pre-surgery testing: $$-$$$
- pre and post-surgery time loss: $$$$+?
- post surgery rehabilitation: $$$-$$$$
- injection side effects: $?
- medication side effects: $?
- loss of quality of life: $?
Our hope is that this information gives you a more complete picture of the true costs of treatments for chronic conditions. We believe the best treatment for a patient, is the treatment that is the safest, most effective, and least expensive. We also believe the doctor should work with the patient to determine what that treatment is on an individual basis. With that in mind, we offer in-person and teleconferences for consultations free of charge. Contact us today.