Why Isn’t Regenerative Medicine Covered? Dr. Aneesh Garg, DO, CAQ on the Real Cost

Transcript

Speaker labels are inferred from the caption export’s turn markers (a short question is Nicole, the practice manager; the rest is Dr. Garg). Dollar figures spoken on the recording are shown as [amount] in this lightly edited transcript. One short remark was omitted from this transcript.

Hook: The elephant in the room, regenerative medicine isn’t covered 0:04

Dr. Garg: Welcome to the Regen Doc podcast powered by DynamicAthlete.com. I’m your host Dr. Aneesh Garg. I’m Yale trained, Andrews trained, and a two sport US national team doctor here to help you make sense of regenerative medicine. The insurance question, why isn’t regenerative medicine covered and why is it still worth it? Let’s talk about the elephant in the room. Regenerative medicine isn’t covered by insurance. And I know that’s a barrier. So, let me be completely transparent about why it’s not covered, why I think that’s going to change, and why in the meantime, this might be the best investment you make in your body. Let’s get into it.

Why insurance doesn’t cover PRP or stem cells 0:47

Dr. Garg: Why doesn’t insurance cover PRP or stem cells if they work? Well, I think the biggest challenge here is that insurance coverage is driven by this reimbursement model that was built for surgery, medication, and managing your symptoms, not necessarily these regenerative medicine approaches. So, it’s not that the treatments aren’t working or they failed. It’s really the system that it was created under where the insurance model generally looking is primarily out out for profitability first and foremost it’s a business and then secondary taking care of patients I think in that in that sense and so I think it’s a systemic problem that the system has failed to keep up with science and so this is where insurance tends to lag by decades. And so even when shockwave was originally covered and then not covered, doctors and and a lot of places stopped covering it, but the treatment itself didn’t change. It’s just the fact that the economic incentive did and that’s where the gap is.

Not covered does not mean not supported by the evidence 2:03

Nicole: If insurance doesn’t cover it, it must not be proven, right?

Dr. Garg: I think that’s what people get wrong a lot. You know, we talked about the gap in the system prior and what people get wrong is just because it’s not covered by insurance that it doesn’t work. And so if you look at corticosteroid injections and we’ve done a lot of talking about why people shouldn’t get corticosteroid injections that they should look at this and say just because that’s covered by insurance […] And so if you’re looking at getting things covered and fi figuring out a way and say, “I’m only going to do things that are covered,” I think you’re going to be missing out on a lot of really good things. And then and then you get stuck in that treatment gap where, well, my PT is covered by insurance. Yes or no? That’s also changing. My steroid injection is covered and then my surgery is quote unquote covered. In the advent of these high deductible plans and out-of-pocket expenses, you may be sometimes actually paying more from a surgery standpoint that you didn’t need versus getting a regenerative medicine treatment. So that’s one PRP. If we talk about that, there are plenty of really good evidence papers and studies that are out there. People want that, right? uh the shockwave, the focused shockwave has FDA approval in in that sense. Stem cell research, you start to look at minimally manipulated, meaning you’re taking it from the body, processing it, and injecting right there. We’re not talking about amplification or doing a lot of these things that are done outside of the country where things are not regulated in in the country here. And so there’s an there’s absolutely an opportunity for it. And I think as we continue to see this and as people pay attention, you see that wow, there’s a lot of truth behind this. And and I think just because it’s not covered by insurance isn’t a good enough answer to negate trying to do that. So my, you know, my challenge with this is that just because it’s covered by insurance doesn’t mean that it’s good for you. And so if you’re continuing to get these steroid injections or you’re continuing to get these things are not working for you, I would really look at seeing why am I making these choices? And and I think it goes back to also if you’re going to be paying out of pocket for things like shockwave. Know what shockwave actually is. We’re talking about focused shockwave. And I

Not all shockwave is shockwave: radial pressure wave vs focused 4:49

think this is another thing that people get wrong is they think all shockwave is the same. I just had someone send me an article, a research paper about shockwave and I started digging into it and I said this isn’t shockwave, it’s radial pressure waves. So this research paper that the big headline talks about shockwave, it’s actually false. But people don’t know that and they read this paper and assume that this is the shockwave sort of umbrella term and they’ve got it wrong and and so that’s not applicable to what we’re talking about here. So if you if you’re now paying money out of pocket but you don’t know the difference between what’s shockwave and what’s not and then you wonder hey this didn’t work or this didn’t work fully shockwave doesn’t work then you can see how it starts to feed on itself in that in that space. So, I think that’s a big thing. We always tell people that if you’re like, “Boy, I didn’t know there was a difference between shockwave and maybe what else I’m getting in the community where they may only have radial pressure wave.” Just go to DynamicAthlete.com and you will be able to read on a host of different things in terms of what is radial pressure waves, what is shockwave, focused shockwave, what’s EMTT, really the difference between PRP even and stem cells and pelvic floor therapy and mental wellness help. So there’s a lot of different things where if you go to DynamicAthlete.com, you can educate yourself a lot on that and see see if things make sense and certainly look around and get yourselves educated on that.

Knee replacement vs PRP: the real cost math 6:30

Nicole: How does someone think about the cost of regenerative medicine compared to surgery?

Dr. Garg: Well, a knee replacement can cost anywhere between [amount] and [amount]. It you have 6 to 12 months of recovery, the time off of work. So, there’s a cost and everything involved, right? Just because it’s covered by insurance, quote unquote, doesn’t mean that there’s not other expenses involved with it. So when you compare doing a PRP injection say with hyaluronic acid for your knee for knee arthritis, fraction of the cost of the surgery, no surgical complications, no anesthesia, pretty much no time off at work. So even if you pay entirely out of pocket, the math often favors the regenerative medicine treatment management versus getting the surgery or the steroid injection. And even I I’ll even go to say that when you’re doing regenerative medicine, I would tell you to go get the best that you can because otherwise you’re going

Price shopping and paying twice: the USA Hockey story 7:45

to end up paying twice, right? If you price shop on a PRP or shockwave and stem cells and you start to look at this as if you’re going to the grocery store where you’re going to buy a gallon of milk, you’re going to buy a loaf of bread, you’re going to get a PRP injection, and I’ll get some bananas. And if you start to look at it in that way where you start to look at which price point am I going to go after versus looking at outcomes, I think you’re going to end up paying twice. We had a guy I was actually traveling with USA hockey for for a tournament and this guy wanted PRP and I said, you know, I’ll be back in a week to 10 days. We’ll be able to do it and then go from there. He couldn’t wait. Didn’t want to wait. Whatever the reason was, went to some place. They drew about 10 cc’s of blood, which is about a vial, and then added something to it and then injected 10 cc’s back into where he was hurting. And it didn’t. And then after a few weeks, he came and called and said, “Hey, I had this done. It’s not working. What do I do?” And I asked him to go through it and tell me all the specs on actual procedure. And I told him, I said, ‘I hate to tell you this, but they basically just took blood from you, spun it once, and then injected the whole thing back into you. So it’s as if they just took out blood and just injected it to where you were hurting. And that’s that’s not PRP, right? But it’s marketed as PRP. And this guy now came back and he said, “Okay, fine.” Like, “We’ll do we’ll do it here.” And then he did great. And all the way through the process, he goes, “That’s not what they did. That’s not what they did here. That’s not what they did here.” And he could tell the difference between what we do and versus what was done elsewhere. Same thing with shockwave, same thing with stem cells. I mean, you name it. And I think that’s part of where now people are educated on, oh, I should go get PRP for this. The next step here is what type of PRP am I getting? And who am I trusting with the money that I’m going to spend here with this, right? Because I think I think anybody can go get a PRP kit. Anybody can go get a Shockwave. We’ve had people that have bought shockwave devices quote unquote off of Amazon and then they market that they’re doing this or they talk about the radial pressure waves. There are plenty of places that market shockwave but it’s actually not shockwave because they’re using radial pressure waves. So for those of you out there that are thinking that they’re actually getting shockwave and the only device that is being used is a radial pressure wave and it sounds like a high-owered massage gun and it’s sort of this pop pop pop feeling or that noise and the feeling is as if it’s a high-powered massage gun where they’re moving it around and and doing that. That’s not shockwave. you’re not buying shockwave treatment. And that’s okay. There are some cases where the radial pressure wave will work, but that’s not shockwave. So, I don’t have a problem if that’s what you’re using and that’s and that’s what’s going to be utilized. But just just know that that’s not shockwave. And that’s not just coming from me. That’s coming from the International Society. That’s coming from the American Society. That’s coming from the American Shockwave Training Institute. So that’s the naming convention. And you see a lot of the the really well-known top people in the field don’t call it shockwave. So that’s that’s just an aside, but and that may also be contributing to why why the insurance model isn’t isn’t covering some of these things because there’s such a wide discrepancy of it. I think you really just need to do your homework on what what really matters. So

We buy back time: money, time, pain, or missed life 12:02

getting back to the question in terms of from a cost perspective, the real cost isn’t the treatment. The real cost is am I going to the right place? Am I getting the right treatment? Am I getting what I should be paying for? And then really, we talk about this a lot in our clinic. We buy back time. So the cost is inherent in anything that you do. You’re going to pay for it one way or the other. Either you’re going to pay for it with your money or you’re going to pay with it with your time or you’re going to pay with it with your pain or you’re going to pay with it with the inability to play with your kids or you’re going to pay with it where you’re unable to play and do the things that you want to do. So then you have to figure out what you’re willing to give up and pay because it’s coming either way. There’s no free ride in anything that you do. So I think the biggest thing is that the regenerative medicine space has the ability to buy back time and that’s what we do in our office.

Nicole: How do you advise your patients to think about the investment?

Dr. Garg: I think it’s about patient experience. The most patients who invest in regenerative medicine treatment say the same thing to me all the time. I wish I did this sooner. I wish I knew you were here. I wish I knew you were here before I tried this quote unquote shockwave treatment. I wish I knew this before I went this surgery and it still didn’t help me. I wish I knew this before I got PRP somewhere else or I got stem cells somewhere else and it doesn’t compare to what you guys do. So, think about this now. Now you’re paying twice, sometimes three times because you’re price shopping or you’re not looking at, hey, is this really the diagnosis? Are we really targeting my injury? Is this a proper plan? What’s the followup? all these things that we take into consideration, you know, and even if you look at it where you have a 50-year-old business owner, spends some money on PRP versus [amount] on a knee replacement, and he’s back to activities sooner versus 6 to 12 months from a recovery standpoint. So, not only did he save money, but we bought back his time. I say this all the time that what we do in our clinic, we buy back time. So, what is your most valuable resource in this world? It’s your time, bar none. So if you can buy back time, if we can buy back six months of more activities and painfree, that’s real return on investment. So, I think that’s the biggest thing that if people are looking at it from a purely economic standpoint and they can’t afford to do it, but they can afford to do some of these other things, then what what I’m laying out here hopefully makes sense of the numbers. Sometimes I would tell you you can’t afford not to do it because of what we’re talking about here, right? If you want to be able to do this, especially if if people are getting paid to compete or to excel professionally in a particular area, buying back time’s huge. We talk about even in some instances, how do we how do we buy back seconds or minutes in a race, right? You want to get faster, there are things that we can do to get you faster. And it isn’t performance-enhancing drugs or anything like that, but it’s how do we optimize you as a person. So, that’s really the big thing that I would say that in this when you’re thinking about this investment, I would think about certainly the monetary investment, but the ability to buy back time and that return on investment.

Honest take: I wish it was covered, and the takeaways 16:15

Nicole: What’s your honest take on the cost question?

Dr. Garg: Yeah, I wish I wish it was covered in a sense like I would love to take it from the insurance companies rather than the person sitting in front of me. I think that’s the challenge here and I think the scope and uh and I think the big thing is that when you have things that are covered the reimbursement and how things are become uniform and there’s sometimes a quality drop and I think that’s the struggle where if it’s uniformally across the board that PRP is [amount] and it doesn’t really matter where you go because that’s what it’s going to be. Then it becomes commoditized and it’s not really an outcome. Then there’s really almost no incentive for the person doing it to get you better. They’re going to get paid in that regard because they know it’s going to be a certain level. And you know, I think people come and see us because we get really good outcomes and they’re willing to pay for really good outcomes, you know, and I think and I think that’s really the big thing. So, as the as the current climate in terms of reimbursement and how do you think about the cost perspective, I think you have to look at what are you willing to invest in? If your coffee in the morning is worth more than some of these other things, then so be it. If you’re getting some of these things where where these are choices that you’re making versus your health, totally fine. I’m not talking about groceries. I’m not talking about feeding your family. I’m not talking about the basic life necessity things. That’s not at all what I’m talking about. But I think there’s choices that people have to make, right, in terms of their health or some of these other things. And can we again what are you going to buy that’s going to buy back time for you? I don’t think there’s anything out there in the health in the health space. You know, you talk about biohacking and some of these other things. And so this is this is muscularkeeletal injury biohacking if you want to look at it in that sense. But I think it’s really important to be upfront, transparent, honest about what the these are. And we talk about not being the most expensive, not being the cheapest. you try to value what you’re doing and try to be a resource for the community and that’s what really drives us. So really the big things that I want people to get away get from this is insurance coverage is really a reimbursement policy not a measurement of evidence. There’s a lot of really good studies out there that show that this works. PRP and these regenerative medicine treatments are actually a fraction of the cost if you look at things in totality. So you’re not and the other thing is you’re not paying for just the treatment. You’re making an investment to buy back your time. Avoid the surgical recovery and maintaining your active life. So if any of this resonates with you, I encourage you to go to DynamicAthlete.com, read about it, educate yourself, and know that there are real options for you in the regenerative medicine space. I know despite being not covered by insurance, but do your homework and go get the best that you can get out there if you’re willing to invest in your health. We’ll see you next time.