Costly and/or Complex Orthopedic Surgeries Goals for Today 1. [PDF]

SLIDE 1

Costly and/or Complex

Orthopedic Surgeries

SLIDE 2

Goals for Today

26-Feb-20 Orthopedic Surgeries - BAN 2

1. Understand the problem;
2. Identify the most common orthopedic problems affecting

commercial groups; and,

3. Describe the effectiveness of “traditional” and newer treatments.

SLIDE 3

Which Joints, What Causes

26-Feb-20 Orthopedic Surgeries - BAN 3

1. In commercial populations, the commonest joints

requiring intervention are shoulder and knee;

2. Wrist and back are also impacted; and,
3. “Overuse” injuries are common.
4. Elevated BMI and diabetes can be contributing

factors;

5. “Overuse” injuries often become Worker’s Comp or

long-term disability issues.

SLIDE 4

Extent of the Problem - Prevalence

26-Feb-20 Orthopedic Surgeries - BAN 4

Hip Replacement Knee Replacement

Women Men Women Men < 50 0.1% 0.1% 0.1% 0.1% 50 - 59 0.8% 1.0% 1.8% 1.2% 60 - 69 2.1% 2.1% 5.5% 3.6% 70 - 79 4.4% 3.8% 10.1% 7.3% 80 - 89 6.3% 4.8% 11.0% 8.8% 90 + 6.1% 4.8% 7.4% 7.4% 2,500,000 individuals living with hip Implants 4,700,000 individuals living with knee Implants 75,000 366,600

SLIDE 5

Extent of the Problem - Cost

26-Feb-20 Orthopedic Surgeries - BAN 5

Description Total* Cost Carpal tunnel syndrome, w/o surgery $374 Carpal tunnel syndrome, with surgery $4,183 Surgery Cost $3,809 Joint degeneration, localized - knee & lower leg, w/o surgery $780 Joint degeneration, localized - knee & lower leg, with surgery $15,720 Surgery Cost $14,940 Joint degeneration, localized - shoulder, w/o surgery $839 Joint degeneration, localized - shoulder, with surgery $15,024 Surgery Cost $14,185 Joint degeneration, localized - back, w/o surgery $1,353 Joint degeneration, localized - back, with surgery $19,592 Surgery Cost $18,240 * Allowed amount

SLIDE 6

Costs- The High End

26-Feb-20 Orthopedic Surgeries - BAN 6

Costs for complex surgeries (for example, “redos”) can easily reach $75,000 - $100,000 (in addition to the cost(s) of a first therapy.

SLIDE 7

Common Injuries: Common Factors

26-Feb-20 Orthopedic Surgeries - BAN 7

1. Involve complex joints;
2. Primary issue is pain;
3. Significant treatment failure rates historically,

especially for back, knee and shoulder;

4. “Overuse” injuries are common.
5. Elevated BMI and diabetes are contributing factors;
6. “Overuse” injuries often become Worker’s Comp or

long-term disability issues; and,

7. Tendency for injuries to become “chronic:

SLIDE 8

Commonest Structures Involved: Shoulder

26-Feb-20 Orthopedic Surgeries - BAN 8

1. Commonest injuries are

to the Glenohumeral joint and tendons associated with the rotator cuff.

2. Both are associated with
verhead lifting or other
ver-the-head work.
3. 250,000 repairs annually.

SLIDE 9

Traditional Treatment- Shoulder

26-Feb-20 Orthopedic Surgeries - BAN 9

1. Initial treatment is usually non-surgical.
2. Failure rates can be as high as 85%!
3. When conservative care is ineffective, a variety of

surgeries can (usually tendon transfer)are employed.

4. Surgical “Failure” rates can be as high as 90%.
5. Failure is often due to the lack of “regrowth” of the

bone-tendon connjection.

SLIDE 10

Commonest Structures Involved: Knee

26-Feb-20 Orthopedic Surgeries - BAN 10

1. Commonest injuries are to the

menisci, ACL and patellar tendon (not shown here).

2. Both are associated with improper

lifting mechanics, “weekend warrior” behavior, and elevated BMI; and,

3. 200,000 ACL reconstructions at a

cost of $2 - $3 billion annually.

SLIDE 11

Traditional Treatment- Knees

26-Feb-20 Orthopedic Surgeries - BAN 11

1. For incomplete ACL tears, traditional treatment has

been conservative (physical therapy and pain medications or surgical; results in less severe cases have been good.

2. For more severe tears, if left untreated, 66%-85% of

individuals will continue to have pain and instability resulting in significant long-term issues;

3. Definitive treatment is surgical tendon transplant; the

procedure has a 25% failure rate.

SLIDE 12

Traditional Treatment: Back Disorders

26-Feb-20 Orthopedic Surgeries - BAN 12

1. Treatment of back disorders follows a similar pattern with

conservative care early on wiith surgical repair reserved for individuals with chronic issues or who meet certain clinical criteria.

2. Epidural or facet joint steroid injections (long a staple of therapy)

have recently been shown to lack long-term effectiveness.

3. National guidelines no loner recommend early complex imaging or

surgery because of their ineffectiveness;

4. Even when surgery is performed, failure rates are high; and,
5. Individuals failing surgery often become chronic pain patients with

attendant problems of disability and opioid abuse.

SLIDE 13

Administrative Solutions- Not the Answer

26-Feb-20 Orthopedic Surgeries - BAN 13

MCOs have tried several solutions:

1. Bundled pricing- savings are minimal and long-term
utcomes are not improved;
2. Utilization management techniques (such as

preapproval) do not change outcomes or materially impact costs; and,

3. “Centers of Excellence”- performing a fundamentally

ineffective treatment well does not make it effective.

SLIDE 14

Orthobiologics

An answer?

26-Feb-20 Orthopedic Surgeries - BAN 14

SLIDE 15

Evolution of treatment

26-Feb-20 Orthopedic Surgeries - BAN 15

Platelet-Rich Plasma Platelet-Rich Fibrin Mesenchymal Stem Cells

SLIDE 16

Rationale

26-Feb-20 Orthopedic Surgeries - BAN 16

2nd generation platelet products contain growth factors that stimulate tissue regeneration; If injuries are severe, these preparations may be ineffective; and, The optimal method of preparation has not been determined. Bone marrow stem cell preparations contain growth factors and cells that can “rebuild” tendons, muscle and bone.

SLIDE 17

Danger: Unapproved Products

26-Feb-20 Orthopedic Surgeries - BAN 17

FDA 12/2019 –”Public safety alert due to marketing of unapproved stem cell and exosome products.” Proliferation of clinics using unapprovedand unproven platelet-rich plasma and other biologics (for example “exosomes”). This is an international (“medical Tourism”) problem.

SLIDE 18

A Reliable Alternative?

26-Feb-20 Orthopedic Surgeries - BAN 18

Regenexx is a BAN partner:

1. National chain of clinics providing advanced
rthobiologic treatments (platelet lysates and bone

marrow stem cells.

2. Treatments are recognized by the FDA and supported

by medical evidence.

3. Utilization management techniques (such as

preapproval) do not change outcomes; and,

4. “Centers of Excellence”- performing a fundamentally

ineffective treatment well does not make it effective.

SLIDE 19

Case Study: Outcomes

26-Feb-20 Orthopedic Surgeries - BAN 19

Regenexx is a BAN partner:

1. Manufacturing Company;
2. 1,486 covered lives;
3. Costs typically 1/3 of surgery.
4. Employer Statement:

8 cases referred to Regenexx from June – December 2019 have avoided surgery, recovered extremely well, and returned to work within 7 days or less. The other tangible cost is the savings we are achieving in our

productivity. Typically, these cases would be out of work for 6-8 weeks, and

at lost production time

f $82.00 per hour, per employee,

SLIDE 20

How it works

26-Feb-20 Orthopedic Surgeries - BAN 20

All components of treatment are outpatient; Platelets are obtained from blood or bone marrow aspirates; The injectables are prepared in the laboratory; The preparations are (needle) injected into the site of injury. Significant cost advantages over surgeries.

SLIDE 21

Conditions Treated and Network

26-Feb-20 Orthopedic Surgeries - BAN 21

1. Nationwide network;
2. All common orthopedic conditions treated.
3. Convincing peer-reviewed medical evidence available

for knees, shoulders, and backs.

4. Long-term success rates are superior to surgery.

SLIDE 22

Coverage

26-Feb-20 Orthopedic Surgeries - BAN 22

1. Most suited for self-insured groups.

MCOs consider these techniques “experimental” and they are usually not covered in a fully-insured scenario.

2. We expect coverage rules to change

for Orthobiologic treatments

SLIDE 23

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* > * 2 L ] H * / > / + * . \ : 8 H > * . ]

3

1 2 L ] , / 2 * 3 * .

2

* / , ] 1 O / / 51 ] : 4 / < 8 . 2 G

]
S

B T h