Episode 29: How to Address the Promise and Challenges of New Therapies

When there is skepticism and apprehension about emerging treatment options, where do providers turn to learn more? On this episode, Dr. Ariana DeMers explains the first steps that she recommends for providers to educate themselves on newer therapies, using the example of orthobiologics. You’ll learn how organizations like the Interventional Orthopedics Foundation (IOF) are becoming the epicenter for accurate information on everything about new treatments – from reimbursement questions, to how new primary care models can benefit referrers.

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Full Transcript

Announcer: It’s time to think differently about healthcare. But how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans. And many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together. And here’s some amazing stories along the way. Ready for a breath of fresh air? It’s time for your Paradigm Shift.

Michael: Welcome to the “Paradigm Shift of Healthcare” and thank you for listening. I’m Michael Roberts with my co-host Jared Johnson. On today’s episode, we’re talking to Dr. Ariana DeMers from Restore Orthopedics and Sports Medicine in Sonora, California. She’s a board member of the Interventional Orthopedics Foundation, group that focuses on education in the field of orthobiologics. Hi, Dr. DeMers, and welcome to today’s show.

Dr. DeMers: Hello, thank you so much for the invitation today. It’s great to be here.

Michael: It’s our pleasure. It’s definitely our pleasure. So we’re just gonna dive right in. First off, let’s talk about what drew you to this field? What drew you to the field of orthobiologics in the first place?

Dr. DeMers: Well, as you know, I’m an orthopedic surgeon and orthopedic surgeons have a long history trying to treat orthopedic injuries or disease with minimally invasive techniques. And we also have a long history of harnessing the body or directing the body’s innate healing power. And so really using those two thoughts, we’ve been interested in orthobiologics for a long time. I think this new trend of minimally invasive or needle-based therapy fits really well with the orthopedic surgeons’ mindset.

But specifically, what drew me to orthobiologics, from a needle-based-treatment perspective, orthopedics, there’s a lot of risk, both for the patient and for the physician when we’re doing these maximally invasive procedures. And even if we say it’s minimally invasive, let’s be honest, orthopedic surgery is pretty invasive. And so I was feeling really exposed, and I was looking for a way to decrease the risk to both myself and for my patient. And I started looking at what was out there and what could be done and what was available. And what kind of support or evidence was there.

There’s some really compelling outcome for common orthopedic injuries and diseases that really starts pushing your thought process to say, “Okay, if there is similar outcome, then why are we exposing ourselves, to both the patient and the physician, to our increased risk?” And then so that’s where I started really kind of delving into how do I go about doing this? How do I go about becoming that expert, getting to the cutting edge of medicine where we are decreasing the risk for both the patient and the physician with similar outcomes? And that really has to be important.

Michael: Absolutely. We work with a lot of orthopedic surgeons. And, you know, one of the main things that we’re always trying to help patients overcome, or at least patients wrestle through, is the fact that it’s a big commitment. If you’re going to go get a hip replacement, that is a major procedure. And it’s advanced tremendously, you know, since they started doing it. But, yeah, there is a lot that goes into it. There’s a lot of recovery time. There’s a lot that happens there. So I certainly understand where you’re coming from on that.

So let’s talk about orthobiologics. It’s still a relatively new field. With any new field and with any new like treatment form there’s a lot of skepticism, there’s apprehension that can go into that. So you’ve talked some about, like, what drew you to it. I’d love to hear some about how you take that on. How do you face… I’m gonna put this as a two-part question. One, I guess, how do you help patients face that apprehension towards this new treatment? And then how do you have this conversation with other doctors?

Dr. DeMers: Yeah, so I’ll address the first one, talking about the patient, because that’s really important to me. And basically, the way that we have to have this conversation with our patients is one of guarded optimism. And saying, you know, “Here are things, here are our problems that are reasonable to consider all options.” And that’s how I start the conversation and I do have the luxury of being able to discuss non-operative and operative treatments for my patient’s condition. Because I have been doing that and I’m a surgeon and so that is something that I’m comfortable with. And where orthobiologic fits is that space in between conservative treatments, such as physical therapy, or cortisone or those kinds of things, diet, bracing, and physical…the space where you’re talking about surgical intervention.

And so I think for a while we’ve had this problem in orthopedics specifically, but in other realms where we have tried conservative therapy, and it has not given a perfect outcome. Yet, the patient’s either not ready or not willing, or they’re not a candidate for surgical intervention. So they’re stuck. They’re left sitting here with a problem that has not been addressed. And yet they’re not a candidate for or not interested in maximally invasive solution either. And that’s really where orthobiologics comes into play.

And it’s quite powerful to now have a new tool in your toolbelt to be able to address these patients that are sitting in front of you every day saying, “Well, Doc, I did my physical therapy, and I did this injection, but I still hurt, I still can’t do the things that I love. And you’re telling me that there’s no other solution?” Then they’re kind of incredulous. And then as doctors, we’re feeling very unempowered, you know it’s like, “Yep, that’s sort of all we have.”

So this is very, very exciting to be able to share with patients that there is another option. And well, the option does have some detractors, such as the fact that it’s not covered by their insurance company. And that it isn’t new or newer field that there is scientific bearing and there is scientific support for what we’re doing. And so what I share with my patients is I said, you know, “This is, from a risk perspective, it’s much less risk, much less an intervention than surgery. And I think the biggest risk is if your back pocketbook can tolerate it.”

Michael: Absolutely. We were talking a little bit before the show about the advantages and disadvantages of not going with insurance, not working directly with the insurance companies. I’d love to hear, love to just kind of talk about it here on the show as well, just how that’s impacting your experience with patients when that’s not at the forefront of every conversation. It’s not all about the insurance.

Dr. DeMers: Yeah, so I’ve been really pleasantly surprised as to how this has unfolded in my practice. So orthobiologics is not currently covered, but hopefully, as this treatment gains traction and we have increasing number of outcome studies, it may end up as a covered benefit for a lot of patients with insurance. But currently, it’s not covered by any of the standard commercial insurances. And so what that allows me to do is have a much clearer conversation with them and say, “Listen, this is my time, you can pay for my time, my expertise.” But what they get is they get an hour with a physician with no interruptions. They’re not limited by their insurance. We can talk about anything that needs to be talked about to enhance their health and wellness.

So while they did come to me, then they want to know about stem cell treatment or PRP orthobiologic treatments for their shoulder, “Oh, by the way, I’m also having, you know, knee arthritis and I’m having trouble losing weight because I can’t exercise.” And so we have the ability to really delve in to wellness, and how to optimize each patient’s wellness, from the whole person perspective. And it’s been so enjoyable for me to really get to know my patients and know all of the parts that kind of play in to their overall health and wellness. And specifically, what’s going to be detrimental or a benefit to a orthobiologic treatment that we’re considering.

And so I have that luxury to be able to spend this time with my patient. And, you know, to be honest, as a patient, that’s a luxury to be able to spend an hour with your physician, talking about all of the parts of your health that are going to ultimately affect the outcomes of this treatment.

Michael: One of the frustrations I hear from family members is, “I go to this specialist and we talked about this one thing. And then I go to this other specialist and we talked about this one thing.” They’re worried that nobody’s considering that whole picture. How do I know that this medicine isn’t gonna mess this up over here and that this thing isn’t gonna cause complications with this? And so this is very welcome to hear, very exciting to hear from people because the benefit of specialization is that you do get the physicians that know very much more about that particular thing. But there is this kind of feeling of disconnectedness out there.

Dr. DeMers: Yeah, I would agree that the care has been significantly fragmented. And I also think that the physician who is in charge of trying to bring all of the pieces together is our primary care physicians. But they’ve been significantly disenfranchised. From a financial standpoint, they are not reimbursed for what they bring to the table whatsoever as they’ve been definitely kind of disenfranchised from that perspective. But then also from a hierarchal or state of mind, I think the way public, in addition to the medical community, does not put primary care physicians in the regard that they deserve. To be able to try to take all of these pieces of the puzzle and bring this all back to a holistic view of the patient.

And I think there’s a number of reasons why that happens. But part of it is the fragmentation of care. I think part of it is from the insurance is driving what can and cannot be done for the patient and how much they’re willing to reimburse. As we all know, the reimbursements have been dropping drastically. And it really is a disincentive to actually care for your patient. And so if you are now operating outside of that paradigm of the standard or standard-insurance-driven care, it gives you that freedom to then look at all the pieces of the patient and really generate a very clear way forward for health.

Michael: We recently were able to have a couple of different sort of like primary care models also, like on the show. And one of them, you know, Jared, really Jared you know both of those guests pretty well. But, you know, one of them we had was a direct primary care doctor. And then one of the other, you know, sort of models that we were able to talk about, we were talking with Shawn about Walmart Health, where they come into the picture of trying to supplement that idea of that primary care doctor again.

Jared: Right, Michael. And I think the interesting part about all this is, as we’re exploring the evolution of specialties like orthopedics, and they are directly impacted, of course, by the evolution of primary care itself. And so when we talk with Dr. Farnsworth, who is the DPC or the direct primary care doctor, who incentivizes himself to spend more time per patient. That the care model itself makes it better for him to keep his patients safe and out of the office, instead of inviting them back in his mind by not helping them take care of themselves and be preventive about their wellness.

And then we had Shawn Nason, who designed the customer experience, the patient experience, and the employee or associate experience for the first Walmart Health clinic. They just opened up in Georgia a couple months ago. And from his standpoint, the retail health evolution is just as impactful if not more, because then it does say, “Look, at the end of the day, there’s still business value in a primary care relationship.”

In both cases, in both of those interviews, we heard statistics about the benefits of an actual primary care relationship.  And to me, what I saw is the evolution of kind of coming back to this whole idea of a primary care relationship, meaning that some care models exists now that are making that work again. Because I think when we started to see primary care starts to dwindle and people ask, “Well, do I really need a primary care physician?” It’s because the business model is the old fee-for-service models weren’t even working then. Now all that to say, all that does have an impact on how patients look for and search for new and emerging therapies and who they trust to provide that to them.

I’m curious, you know, what you think about all that Dr. DeMers, in terms of, kind of from the patient’s standpoint as their primary care relationships are changing. How does it impact the way that they hear about kind of new therapies?

Dr. DeMers: That’s really interesting. We live in a rural community that’s been very impacted by lack of primary care. And so I would say that a majority, greater than 50%, of my patients don’t have a primary care physician, which from a specialist’s standpoint is very concerning. And so then what happens is that that need for defragmentation or to try to synthesize a whole patient view then starts to fall on whoever has the time. And if you’re not getting paid for your time, then you’re disincentivized to take that time to be able to formulate that.

And I do I agree, you know, that there should be a financial incentive to have that relationship. There’s not currently in the standard model, but these are really two very interesting models. I’m more familiar with the DPC model, which is brilliant and I think is gaining traction. And we are actually looking to add that as part of our model for specifically for primary care DPC here in our town. So I am really excited to see what can be done.

I think the other thing that does is it takes the financial way that physicians and patients interact. And it takes that discussion out. You know, when you have a membership model, like a DPC model, you pay your fee, and you have unlimited access. That’s feel very different than having to pay every single time that you have to see the doctor. So you start saying, “Well, it’s not that bad. Well, I can look on Google.” And it starts to degrade your relationship with your physician. It’s very exciting to me, because it really does…and you’re right, it’s very clear that it really does matter to have that important relationship with your physician, who knows you and who knows all the pieces about you and then can synthesize with the best way forward.

Jared: Absolutely. And I know this is something again, when we’re talking about those relationships, those referring relationships that is what it’s based on partially are those patient expectations. So that was very interesting to hear your take on that, I really enjoyed that. One kind of thing that I think is related is just overall how orthopedics is evolving. Why don’t you tell us a little bit about the Interventional Orthopedics Foundation, kind of what they’re doing to train other physicians in this field? As of this recording, the organization just held its fifth annual conference, so why don’t we start there. How did that go?

Dr. DeMers: Yeah, so this conference, the IOF Conference, was really quite exciting. And I thought last year’s conference was amazing, really mind expanding and very, very valuable as a conference to go to. Because it is right on the cutting edge of what’s new, and what’s possible and what’s out there. And it’s been really thoughtfully put together. But this year exceeded my expectations based on last year, so this is even more exciting. I think, the basic science that’s out there right now, and the translational laboratories that are out there are creating some really great, compelling science to back up what we all think we know about the field of orthobiologics, but we’re waiting for that science to back it up. Because I think that’s one of the complaints, specifically from orthopedic surgeons is, “Well, show me the science.” And so this is really exciting time where there is science to back up orthobiologic treatments.

And I think if you’re a connoisseur of sciences, these meetings are quite mentally stimulating to say, “Oh, my gosh, there is so much out there that we know. I had no idea how granular our knowledge base is becoming.” But also it opens up that door like, “Holy cow, we still don’t know X, Y and Z.” But the encouraging thing is all of the presenters say, “Yes, we don’t know these things. But here are all the projects that are ongoing currently to answer those questions.” So this was really, really exciting.

I think the other part of the conference that was great was that we were able to have labs, educational labs, both before and after the conference to help educate physicians. So not only are they coming to this conference and getting knowledge, but they’re also able to register for a foundations course in ultrasound and orthobiologics to set the stage. And then in the laboratory testing afterwards, there were labs on the nuts and bolts of how do you actually go about applying all of the things you just learned. How do you go about applying those in your clinic with a take home message and how do you go forward? And so there were labs both on before and after the conference, so I think we’re very, very valuable as well.

Michael: So I was participating in one of those events, kind of the best first step for an ortho surgeon who’s considering orthobiologics or other emerging therapies, what would you recommend?

Dr. DeMers: Ultimately, this has been a source of consternation for me thinking about how do I involve my colleagues in moving forward and being a part of this really, really exciting time in the care of orthopedics? And to be able to make sure that they are providing the most up-to-date, scientific, cutting-edge therapies that we can provide. Well, also bridging that gap between standard conservative therapy and surgical therapy and being able to meet our patient’s needs that are sitting right in front of us. I think going to an IOF Conference is valuable, not only from the educational standpoint, but from the practical standpoint of doing these things, learning these skills. So yeah, I think this is a great way to open the door to what is possible.

And then the IOF, the Interventional Orthopedics Foundation, is a foundation that is committed to education. So they are committed to…they have a standardized curriculum on how to go forward using both ultrasound and fluoroscopy, to be able to use needle-based therapies appropriately. They are right in the middle of creating standards and ethics and guidelines on how to go about ethically in a standardized way applying these therapies. And then also, they’re really working hand-in-hand with legal to make sure that these therapies are FDA approved and that we’re not gonna get into hot water with how we apply these therapies.

So I would definitely recommend going to the Interventional Orthopedics Foundation. But understanding that I do think that is a starting point because they also have a standardized curriculum in how to learn the standards that we use and not just a weekend course on, “Oh, now I’m an expert.” You know, expertise takes time and effort. And that’s what the IOF is able to provide for physicians, not only orthopedic surgeons, but also sports medicine, physical medicine, rehab, pain management, physicians as well.

Michael: Does the foundation have labs at other times a year as well?

Dr. DeMers: Yes, so we have labs throughout the year and they previously were all based, because the Interventional Orthopedics Foundation is based in Denver, they were previously based in Denver. But this past year, we have I’ve been able to hold labs across the nation. And this will mark the first time, in the fall, we’ll be actually holding the international lab.

Michael: Oh, good.

Dr. DeMers: Yeah, this is really exciting and throughout the year they have both… They have a foundation course, which is the very first course, where if you have never used an ultrasound, you don’t even know how to turn it on, you’ve never done cell counting you don’t really even understand the process of it. That foundation course is really important to kind of set the stage. And then they have intermediate and advanced courses for all of the different body part locations, you know, upper extremity, lower extremity, hip, knee, shoulder, spine, throughout the year.

Michael: Very nice. So you used the phrase connoisseur of science. I think that like, needs to be the foundation’s like tagline. Like this is for you know, we put on events for connoisseurs of science. So I love that it’s really cool. I love it.

Dr. DeMers: Well, you know, I mean, you have to have some way, some kind of framework to be able to reasonably and safely move forward with therapies that don’t have… It’s not a fully fleshed out specialty, it’s not. There are…this is new and it but you have to have some sort of framework to be able to provide your patients with a safe, effective, well thought out treatment plan based in science.

Michael: We met at a recent event and one of the things that really just stuck with me was this whole concept of not only are you out there using these new treatments that are out there. But, hey, this is something that you’re committed to beyond just your practice. This is something that this entire foundation is educating other physicians is really advancing this field. So I’m very excited about that. I’m very interested to see where it goes. I know a lot of people are but just really encouraged by this process because there are so many times where patients do get scared by the concept of surgery that they may not be ready for it yet for all the reasons that you mentioned. So it’s great to know that there’s more than one path for some of this stuff.

So, Dr. DeMers, thank you so much for coming on the show. I feel like there’s so many more things we could ask you about and learn from you here. But we definitely appreciate your time today and really look forward to seeing where the IOF goes from here.

Dr. DeMers: Thank you so much. I really enjoyed being on the show.

Michael: It was certainly our pleasure.

Jared: And thanks for listening everybody.

Announcer: Thanks again for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neuro practices. Subscribe on iTunes, Google Play or anywhere you listen to podcasts.