Let's Talk About Money

Discover the keys to unlocking productive discussions about money, ensuring transparency and understanding with your clients. Learn how to showcase the unmatched value of your Orthobiologic solutions while navigating cost concerns seamlessly!

Maximize profitability in Orthobiologics now! Tune in to this episode to learn how.

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Transcript

Intro

Hey, I'm Dr. Ariana DeMers. I'm an orthopedic sports medicine surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective, but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for help. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.

Dr. Ariana

Hi, welcome to the session on Let's Talk About Money. Here's what we're going to cover. Value versus cost, how to talk about money in a cash practice, don't assume anything, and steps to an easy conversation about money. Now, let's talk about the difference between value and cost. Value is a benefit over cost. Benefit can be quality and service, and cost is the price. We have seen a big shift in what people value during this pandemic and after the pandemic. What do people value when everything changes? Now, we will be talking a bit about realizing value not only for our patients but for our physicians and our healthcare system at large. So for value for the patient. The benefit today is looking at post-pandemic. We're seeing unmet needs that are identified and addressed. This is less invasive, less downtime, more natural, more improvements, and less visits. It seems to be a treatment that's taken care of outside of the hospital, but at what cost? So let's look at some examples of the standard treatment of arthritis. So standard treatment of arthritis costs is physical therapy, 12 visits at $200 a visit, equaling $2,400 a visit for the total. Steroid injections, $200. Hyaluronic acid injection, $2,400, $2,500, unloader bracing, $1,500 if you're covering with insurance, $495 if you pay cash, with the total being $6,600. If you have to pay your 20% copay, that's $1,320. Now, treatment of arthritis for a surgical total joint arthroplasty, the anesthesia cost is about $3,000. Implant cost about $5,500. Hospitalization, 1-2 days, 20-40,000. Surgeon's fee, $1,500, and that's the total of $52,000. And if you have to pay the copay, 20%, that's $10,400. Now, treatments for arthritis with orthobiologics price, looking at a one-hour consult for $400, bone marrow harvest and injection, the kit costs about $1,500 to $2,000. Physician times, $1,000 for physician time. Clinic processing costs $600. Ultrasound or fluoroscopy, $1-$400, registry, $200, unloader bracing, $500. Follow-up evaluation, $200. For a total of $5,300. So, to compare, the standard total joint or standard treatment was $6,600, total joint was 52,000, and orthobiologic treatment, including all of the things that come along with it, it was 5,300. Remember, value to the patient is benefit over cost. So what's the benefit? Evidence is limited for most of our standard treatments, including joint replacement, including steroid injection. Our registry data shows encouraging functional improvement with orthobiologics in 40-75% of the patients. These outcomes are approaching surgical treatment outcomes without the same risk profile. It's less invasive and less downtime. So when we talk about value, we talk about orthobiologics being at the highest value, standard conservative treatment being next, and surgical considerations and treatment being next. So then what are the costs? Evidence is limited. Cortisone has more risk and limited benefit. These outcomes are approaching those surgical outcomes. But how about the time? How many visits? Imagine if all the people would choose what they would choose if all options were paid out of pocket. Obviously, we'd talk about the cost being the least cost, highest value would be orthobiologic, standard of conservative, and then surgical treatment. So that's something to think about. Now, let's talk about value to the physician. Value being better service, lower cost. So why should physicians consider using orthobiologics in their practice? Patients are looking to you for solutions. Also, many musculoskeletal conditions have very unsatisfying surgical as well as non-surgical outcomes. Consider insertional Achilles tendinopathy, partial thickness rotator cuff tear, and trochanteric tendinopathy. Many have had disappointing results, regardless of treatment plan. Additionally, physicians have the initial skill set and clinic flow to start with a low-cost, minimal effort to include orthobiologics in your practice. In this post-pandemic world, this may save your business as reimbursement continues to decline, deductibles continue to increase, and we have a paradigm shift to value as the most important thing. Now, with our jobs, with physicians, we see the current value of our jobs. We continue to see declining value due to service over cost with decreasing quality and service, increasing cost. So our decreasing quality and service is limited time with our patients, increased burden of patient volumes, more documentation time. Our increasing cost is increasing administrative tasks, declining reimbursement for both in-office and in-surgery, limited hospital and clinic support. And so really the value currently without orthobiologics continues to be low. Now let's talk about financial drivers for value. We have declining reimbursements, an increased burden of patient volumes, so we're getting paid less to do more. And then satisfaction drivers, we have limited time with patients, limited support from your hospital or clinic, and less autonomy. So we're being required to do more with less. Let's talk a little bit about this value problem for physicians. As an example, current Medicare reimbursement for ultrasound-guided injections is somewhere between $41.76 and $61.86 for a skill that is learned that improves patient outcomes as well as accuracy. I don't know about you, but I don't feel very valued for $41 for an injection for my skill. This is a race to the bottom. We have less reimbursement, more documentation, more administrative burden, less autonomy, less career satisfaction. This is a bean, counters heaven. So let's review the numbers. In a standard orthopedic clinic at the employed model, we're seeing 25-30 patients a day. It's about $2,000 a day times three days a week is about $6,000. That's assuming that your RVU, your 99213 with a 0.7 RVU at $75 an hour, you get about $83. With a 1.5 RVU of 99214 at $75 an hour, that's $121. 99203 is $122, 99204, $184. Global visit still is zero. Now, add your 4-8 surgeries per week on top of that, somewhere between the 3,000-7,000 reimbursement range, obviously, total knee arthroplasty reimburses about 1,500, carpal tunnel reimburses about 435 dollars. This is going to be variable depending on specialty. So your week total is about 16,000 all total. That is a very busy standard orthopedic clinic. Working about 60, 70 hours a week. If we look at an established, non-operative orthobiologics clinic, this is a private practice model. You do procedures two days a week. So you do three BMACs procedures, five PRP procedures, with a total for the BMAC being about 13,800 and the PRP total being about $5,000. You also see about 10 patients a day, three days a week at a total of 9,600, maybe four consults at $400 a piece, and four follow-ups at $800 total. For a week total of 28,400. But remember, we're in private practice, so we've got to take 50% of that for overhead minimum off the top. So your total is going to be 14,200. Now, if we look at a hybrid practice, a private practice model, orthobiologic procedures one day a week, two BMACs, 4,100 times 2 is 8,200. Three PRPs at 1,100 a piece at 2,200. Ten patients a day at 2,400 for two days, which is 4,800. Six consults is 2,400. Follow-ups, we still charge zero for that as a package deal. So our week total is about $15,200. Then we have to add on those orthopedic patients, 20 patients a day times one day is going to be $2,000. And surgeries, four surgeries a week, about $3,000 to $7,000. So that is a week total of $8,000 times 50% for overhead. And so that's $4,000. So the week's grand total for all things is $19,200 after overhead has been taken. So this is valuable to add orthobiologics to your practice. Remember, value is benefit over cost. So, how are we winning the race for physicians? Remember, a standard orthopedic clinic is 16,000 a week with 96 patients versus an established orthobiologics clinic, which is 14,200 a week with 28 patients a week. 96 patients a week or 28 patients a week. This is valuable. This is two-thirds less patient interactions, which means you could have more meaningful patient interactions, less rush, 70% less dictation, happier patients, and happier doctors. So, how do we win the race today? This provides flexibility. In post-pandemic, it's not either or. This is an and. This is an add-on. It gives you the ability to flex the type of interactions and care you provide, depending on your ability to operate or do in-person visits. This allows for shutdowns. This allows you to pivot your business for your health. It provides an option to patients who aren't ready for surgery, don't want to go to the hospital, or cannot have surgery due to medical or other considerations. So where do you start? The cost of a startup is low. If you get an ultrasound, you can pay about $2,500 for a point-of-care ultrasound, $40,000 for a top-of-the-line ultrasound, and if it's sitting in your corner collecting dust, it is free to you. The PRP kits are about $200 to $300 per kit. If you're doing it yourself, you can get a centrifuge for about 800, sterile processing, and a countertop hood for about 1,800. Your credit card processor, the Square credit card processor is free. And the ultrasound course, you've already done. So what's holding you back? Now, I did want to take this time to also discuss this last piece of the value puzzle, which is value to the orthopedic health care system. Now, currently, there are 30,000 Americans with arthritis. It's 600,000 total joints every year, with the cost of a total joint being about $50,000. The cost of the system is 30 billion. Yes, 30 billion. Now, if we were to decrease the total joint replacement by just 10% using orthobiologic treatments, that decreases the spend by three billion. Yes, three billion in savings with our healthcare system. Remember, current conservative treatment isn't free. It's as expensive or more expensive than orthobiologic treatments. Remember, the steroid PT, hyaluronic acid, bracing is $660 with $1320 out of pocket. 80% of treatments are PRP, so that's a thousand to $1500 out of pocket. 20% of treatments that in my clinic are BMAC or Adipose, $5300 out of pocket. Really, just remember, just because it's covered by insurance doesn't mean that is all covered by insurance. So how do you get started at winning? Get educated. That's why you're here. Use image guidance. It's a must. PRP, BMAC, and Adipose are not magic, but they are powerful tools to help your patients get better. Use what you have. We all know that. Ultrasound is sitting in the corner collecting dust. Start slow, collect your data. Use it for cases that have historically with disappointing results. And PRP is a great workhorse. So, be the driver of change. My final thoughts on value. Some say they can't afford to take the time and effort that it takes to add something new to their clinic. But let me ask you this. What's the cost of not adding PRP to your clinic? You have more of the same, less satisfaction, more documentation. You're still on the hamster wheel. You're still in a race to the bottom. So, in conclusion, add PRP to your clinic today. Next, let's dive into the tricky topic of how to talk about money with your patients. Money in medicine is tricky. Our patients want us to be poor, altruistic, and do everything for free. But they understand that it cannot exist in that way no matter how much they want that. Medicine is considered a service-oriented job, but physicians are particularly scrutinized in this. They are considered to be overpaid with lots and lots of money, which turns out is not really the reality at this point in our careers. This dichotomy in medicine is at the crux of the discomfort that we have talking about money and getting paid for the services we render. And really, we've been trained not to talk about it. So, here are a couple of things to consider from a psychological perspective on money with your patients. Sensitivity. Money is a sensitive topic for many people. Discussing finances, even with your loved ones, can evoke feelings of embarrassment, shame, anxiety, and potentially, affecting that patient-doctor relationship. Number two, stigma. Some patients may perceive discussions about money as an implication that they can't afford it, leading to feelings of inferiority or judgment. Number three, transparency or lack thereof. Currently, healthcare costs can be complex, and maybe they're being kept that way. They vary widely and this lack of transparency and pricing can make it really difficult for doctors to provide clear cost estimates, which leads to uncertainty and decreases trust. Four. Misunderstanding. Patients may not fully understand their insurance coverage. I see this so often, especially now with the Medicare Advantage Plan, which is definitely not an advantage. They are so confused. They think they just changed their secondary or something happened and saved a little money. They don't understand the deductibles, the copays, and the other financial aspects of this care, which leads to significant confusion during discussions of money. Second. Logistical considerations. We have time constraints. We are often limited in the time per patient appointment, and it can make it really challenging to thoroughly discuss matters of finance alongside all of the medical concerns that we talk about as well. Additionally, emotional toll to the patient. Doctors may worry that the emotional impact of discussing finances can damage the patient-doctor relationship and may fear that it might distract from focusing on the patient's health, which is the most important thing. Number three, lack of training. Medical professionals are trained to provide medical care, not financial advice. We may feel ill-equipped to address patients' financial concerns, concerns about their insurance coverage, which we are not educated in. And then number four, reputation concerns. Doctors might worry that discussing money could negatively affect their reputation, or they could be perceived as prioritizing financial interests over patient care, and they really are just trying to get paid for the services they render. Next, ethical and legal considerations. Now, there may be ethical and legal considerations around discussing finances, particularly when it comes to perceived conflicts of interest. And so we have to be very careful and very clear that this continues to remain transparent. Additionally, there are some legal aspects in the emergency room where we're doing emergency care where we're not legally allowed to ask about coverage or any insurance-based questioning that is considered illegal. Next, variable costs. Costs can be based on treatments, and they can vary. The insurance plans can vary, the other factors can vary, and this does make it challenging to provide standardized information to our patients. I find that the best practice is to have clear, transparent pricing that is available for everyone to see. Lastly, there are cultural differences. Different cultures have varying attitudes towards discussing money openly, which can impact on how comfortable patients are with financial discussions. Money concerns are not always about money. Please understand, money allows other things to happen, but so much is wrapped up in the discussion and the thoughts about money: someone's ego, identity, social roles, and own judgment. Maybe there's a scarcity mindset that there's a limited amount and there can't be any more. Really be clear and try to figure out where your patient is coming from when we start talking about finances and about money. Next, don't assume anything. We all know to assume is to make an ass out of you and me. Unless you ask, you don't know. Please don't ever assume you know what's in your patient's wallet or what's in your patient's bank account and what they value. Please, please, please, clarify their values, and give them the options. I'm always continually surprised by my patients, so I always present the opportunity and they can always say no. Next. Here are some steps to an easy conversation about money. Choosing the right time and setting. Maybe schedule a dedicated appointment to discuss cost and payment options. Choose a private and comfortable space to ensure patients feel at ease discussing financial matters. Sometimes we can have a couch-located discussion, and sometimes they can go into a private room to discuss it with the financial counselor. I find it best that the physician themselves talks about the finances of the orthobiologic treatments. Next, to open with empathy. Start the conversation by acknowledging that costs can always be a concern for many patients and that you want them to understand their financial considerations. Third, be transparent. Clearly present the total cost of the procedure, including any additional fees such as testing or follow-up appointments. Break down the cost to show how it's allocated and then make sure that they're clear on that. Next, we're going to discuss value and options with the patient. We educate on value. We emphasize the benefits of the potential long-term cost savings of the procedure compared to alternative treatments. You need to explain how the procedure aligns with their health goals and quality of life, and then address any concerns, ask if they have any questions about the cost or the payment options, and then address any potential concerns they may have about the financial aspect of the procedure, including what happens if it fails? What happens if it doesn't work at all? What's the next step? Have I wasted my money? Or is there some insurance or assurance from the practice? Next, you can discuss insurance and reimbursement, explain why the procedure is not covered by insurance and how that differs from standard treatments. You can clarify if patients can submit claims for reimbursement themselves. Then I always recommend that you talk to your patient about the fact that their insurance company is choosing not to cover this benefit and it has nothing to do with the validity of the benefit. It is a choice that their company is making, and other companies make other choices. Definitely, I think that aligns you and the patient together and putting them against the insurance company that's not covering this. If applicable, I would offer payment options. Sometimes you can pay in full upfront or installment plans or financing. For me, I take CareCredit, which lots of people have for the vets or for their dental insurance. Then, as best you can, explain the terms of each option, including any interest rates. I try to stay out of that application process for the CareCredit, but I do offer an application that the patient can take home and see and talk with the company as to what they offer. The next step is to instill confidence. So, please highlight your experience. Describe how your practice provides a high level of personalized care and attention, which contributes to the overall value of the procedure. Display confidence in discussing this financial aspect, which can help patients feel much more assured in their decisions. Two different ways to discuss money can cause two different outcomes. If you talk to the patient and you say, well, yeah. So I think that the price is kind of-- sort of-- a thousand dollars. I'm sorry. Or you can say, yes, of course. This procedure, the price is one thousand dollars. This is what you get. You get X, Y, and Z. It's an excellent value, and I think this can help you a lot. Now, those are two very, very different feelings when you're being talked to about the procedure. Please actively listen and encourage the patients to share their thoughts, concerns, and questions about either the procedure or the financial aspects, and then show that you're listening, actively listening, repeating their concerns back to them with empathetic listening to their perspective. Next, provide written information. This written information gives patients a written breakdown of the cost, payment options, and any terms or conditions. I always give them a written breakdown of what I've quoted them because sometimes I quote the price wrong, and we always want to honor whatever price I quoted when I'm talking to them about money, even if it's wrong. We always write down the exact price that we talked about, and we file that in their chart. Don't forget to follow up. Give some patients some time to consider options. Follow up with a phone call or email to answer any additional questions, and show that you're providing further support. Obviously, we respect the patient's decision and understand that not all patients may be able to afford the procedure or be comfortable with the cost, respect the decision and make them comfortable this is a low-pressure situation. Also, assure the patients that their financial information and discussions will be kept confidential. It's super important. Now, we can feel confident talking about money by recognizing the difference between value and cost. Obviously, we don't assume anything, and we follow the easy steps to an easy conversation about money. Remember, wealth is not about having a lot of money. It's about having a lot of options. Thanks so much for listening. We'll see you next time when we talk about marketing. Have a great day.

Outro

This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more, please join us on the website, "PRP-Now.com", and click on the FREE masterclass. Also, don't forget to "SUBSCRIBE" to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.