Insurance Challenges and Future Innovations

Jordan Beckwith is in her early thirties. She lives on her own, just outside of Denver, Colorado She's got an apartment, a car Two big dogs named Sophie and Leo And a YouTube channel with a million subscribers My name's Jordan Beckwith, but online, my handless footless Joe Pas Joe's origin story goes like this When I was thirteen, I took a very bad fall off of a horse, shattered my ankle. My tibia broke off and then was shoved up into my legs. It was really bad break caused A lot of complications in healing It was about fourteen years of surgeries and trying to walk, trying to be active and be a kid. By the time I was twenty seven and still dealing with all of that, I knew that I was at the point to make the right decision And five years ago in twenty eighteen, I had my below the knee amputation From the time that I sent the email in being like, yes, let's go ahead and do this. I think it was three weeks from then. And it's funny.. I mean, the process is like minor knee surgery or wrist surgery. It's all the same when they're also removing a limb. They come in smiling and they're like, this is the one we're taking off today, right As soon as pain was under control, they keep you there for like three days then they sent you home. What came next was an intense, expensive, and important relationship with her new leg In general, they try to get you up and beginning to use a prosthetic within like six to eight weeks, which sounds very soon, right? Like you just cut off my leg and I'm supposed to start walking on that E Economics Radioetork. This this is the economics of everyday Things. I'm Zachary Cracket. Today, prosthetic limbs In the US, about two thousand babies a year are born missing some portion of a limb. Far more people lose arms or legs later in life as a result of vascular disease or an injury Altogether, more than two million Americans today are living with the absence of a limb Some amputees don't seek out a replacement for their lost limbs Many patients, especially those with leg loss, use a prosthesis And for them, the first step is finding a good prosthetist Joe Beckwith loves hers. He's fantastic Goofy And he does a great job making legs Right now he works with hanger prosthetics Hanger has about nine hundred clinics nationwide It provides prosthetics, which are devices meant to replace limbs, and orthotics, thingsings like knee braces and shoe inserts that support an existing body part from the outside Hanger does brisk business Before it was taken private in twenty twenty two reported annual net revenues of over a billion dollars They are the biggest. I had a lot of hesitations. about Hanger kind of just being like big box prosthetics But I've had a great experience there actually How did you know you had found the right person there's a lot of time that you spend with them. a lot of like, all right, let's try this and see how it works. The relationship that you have with your prosthetist as an amputee is really important There's a lot of trust that's placed in them Yeah, it's a very intimate relationship It's Eric Newfeld He's the owner and medical director of Agile Orthopedics, which is also in Colorado We're among the smaller size in our industry We see about two hundred, two hundred and twenty five prosthetic patients a year what would you major in if you wanted to do this Well, a variety of things. People major in engineering and then go for this masters program that's called an MPO, which is a masters of prosthetics and orthotics. You need to go through a formal certification process, taking a series of exams and going through a residency program. at the end of it, then you are certified And that's your That's your badge What wasas it about it that really hooked you I think it was just the ability to make stuff and solve problems but with a real purpose. You know, when we meet somebody, that's the line of questions that we go through what's important to you What do you like to do? What do you need to do? What's your job It's in most cases, ideally, a lifelong relationship pereriodically maintaining the device, replacing parts, keeping in touch with the patients And your limbs change over a lifetime too. You gain and lose weight, you gain and lose muscle Things happen We've got to keep up with that with their devices. So these are people we get to know very, very well Unlike a doctor or a physical therapist Neufeld is not paid by appointment We get reimbursed by insurance companies or Medicare or Medicaid when the device is delivered, not from the hours and hours of services provided leading up to that or even after that It's a real nuance, but prosthetics and orthotics as a combined field is looped into durable medical equipment. So DM, picture wheelchairs, crutches, beds, oxygen, things like that. whether it's you know, one of those walking boots you get after you fracture your ankle or a very complex above knee prosthesis It's all considered the same financial model that's based on a single item and all the services associated with it is tied into that payment for that device It takes a lot of consultation and time to get these highly customized products right Especially the socket where the prosthesis will connect to its future owner That's the cup that the residual limb goes into custom you know, unique to that person On the socket is an attachment point at the bottom of it where you put on the component tree. And those components could be the knee, the shin section The ankle portion and then the foot and any other features that we're adding to it for suspension methods then a dynamic alignment is performed. So each person walks just a little differently basased on their strength, based on compensatory mechanisms they're using because of the weakness or the loss of that limb And so it's aligned through some of adjustability that's built into the components until it feels safe and performs All that work means that prosthetics are not cheap. Prosthetic limbs, you know, the cost for a below knee prosthesis, it's around fifteen to twenty thousand dollars My first ankle It was an Oser ankle, that was the brand. I believe when I got the bill for it, not the socket, just the ankle itself was about sixteen thousand dollars. Looking through the manufacturer's catalogs, you can see which ankles are rated higher for shock absorption or are waterproof But it's hard to find prices on these individual components They're not generally published online Before a prosthetist can buy a particular model to use in a patient's device, Their clinic needs to negotiate a rate with a distributor or with the manufacturer themselves Either way you tie that together with the sockets That whole process was right around thirty thousand You're talking large dollar signs when it comes to anything prosthetics related. That's just for standard mechanical devices, which Beckwith uses None of them have to be charged There's no computerized parts or pieces You're controlling it just by your body movement and your muscle activity There are also knees and ankles that are controlled by microrocessors and powered by hydraulics and rechargeable batteries These components offer a responsive range of stability and support whether you're standing still or playing basketball The software in these devices has to learn how their owner moves over time the microprocessor controlled knee, for instance. is reading your speed, your slope, how you're walking, if there's been an interruption and you're about to stumble, it knows that because it's taking these readings however, many times per second Bove me with the use of microprocessor componentry, We can get into the seventy eighty thousand dollars range And then similarly, if somebody is missing above the elbow and you're using myoelectrics and exxternally powered devices, that can actually cross the one hundred thousand dollars threshold Myoelectric devices use signals from the arm's remaining muscles to help direct the movements of a prosthetic elbow, wrist, or hand The most Dluxe models can even provide the sensation of touch Think of reaching into your back pocket for your ID The way we use our hands depends heavily on the information we receive from the nerves in our skin But there's also the challenge of proprioception which is the body's sense of where all its parts are in balance, in motion, and in relation to one another It's a vital part of our neural system when it comes to motor control. And engineers in the field called biomechatronics, are making headway But more bells and whistles make a device more expensive and harder to learn. Sometimes simpler is better somebody who had lost her arm above the elbow we had gone through all these different iterations with complex arms to achieve a variety of things, but ultimately, all she wanted to do was hold a carrot on a cutting board That was it And so She helped design something called the carrot arm, which was a very simple socket with a fork just coming out of the end of it No wrist, no hand, no elbow Nothing became more functional to her Basic. or advanced Prosthetics still remain out of reach for some patients I've certainly talked to people in some pretty rough situations where getting a prosthetic is not possible for them for one of many reasons That's coming up If you need a prosthetic and you want your insurance to pay for it It'll have to be approved as medically necessary Proiders' coverage guidelines often refer to a patient's function level and their potential for rehabilitation The patient's physician and prosthetist have to make a case involving their physical ability, their life expectancy, theirir home and work environment Even their grit Eric Neufeld of Agile Orthopedics He says it can be an ordeal quuite a bit of documentation is required both from the prosthetist and the physician who's collaborating and prescribing the device. We have a staff of administrative people fighting with insurance companies, chasing down documentation, you know, the billing, collecting, all that stuff If the request gets approved, then Medicare And many private insurance plans will cover eighty percent of the cost of a new prosthetic device then there are pieces that wear out before they're going to be covered Again, that's Jordan Beckwith AK A Footless Joe So that's an out of pocket expense that either I have to pay myself or I have to deal with a part of my leg not working Generally speaking, every three years insurance will consider covering a new ankle A lot of the components can wear out much faster There is a liner, which is the thing that's directly in contact with your skin. It's a thousand dollars each I can make it last for six months, but that is a stretch There's something called a sleeve, which is if you're using a su section based form of a prosthetic, which a lot of people do. Those things wear out after like two months. If you're an active person, those are like three hundred to four hundred dollars each And I couldn't really walk without it then there's like the foot shell, which is the thing that kind of looks like a foot that actually goes into the shoe. but I was walking on one that had a lot of holes in it for a long time So there's a rationing that comes along with being an amputee for all the additional parts and pieces M Neewfeld has spent time distributing prosthetics in parts of central and South America where many people can't afford professionally made limbs at all bu get very innovative ery creative. We've seen all kinds of stuff, peopleople using upside down soda bottles that are reinforced in a way to become a socket and then attach to just wood, just scrap wood twwine tying everything together and like pretty functional on some of these really cleverly designed and cobbled together devices I've really come to appreciate that kind of innovation that people just from the materials around them have been able to figure something out Researchers at Johns Hopkins have suggested that the number of amputees in the US is poised to double between two thousand five and twenty fifty. That's mostly due to the rising rates of diabetes and peripheral arterial disease. These often go untreated in low income and underinsured communities One development that could make some prosthetics more affordable is the rise of three D printing As we get better and better at creating algorithms and certain ways to process scans to create the sockets through three D printing I do think it could drive down cost and create scalability. you know, for instance A scan could be taken in Ecuador and I could print a socket in Denver that night from that scam. So It allows us to work together in ways that we were never able to before. three D printing is an efficient way to get through the many iterations that it takes to get a socket right There's been significant advances in three D printed hands, arms and even feet though certain parts are still a challenge. Lakes, for instance, generally have to be made from carbon fiber materials, strong enough to bear a person's weight. And that material can't be three D printed Another solution to the cost and accessibility issue is to reuse prosthetic parts Eric Neufeld founded an organization that helps prevent expensive parts from going to waste to just throw it away is heartbreaking. So we do accept ton of used prosthetics from all over the country The sockets are not really reusable. You can't refit a socket on someone else So you know, the recycling effort is in the component tree And we have a process to control quality and inspection and things like that. and we're able to distribute them to manufacturing facilities and labs that are providing custom sockets on site in Guatemala and Ecuador. They use the recycled componentry from donations that are happening here in the United States it's going to really help someone else and change someone else's life. It's a huge win win. For her part, Jo Beckwith will continue sharing her triumphs and her challenges with her subscribers on YouTube I think it's really about figuring out what you want your life to look like and how you want to adjust to that. . I consider myself extraordinarily lucky with the people that I've been able to meet, with the community that I have and a prohatist who fights on my behalf. likeike amazing. For the economics of everyday thingsings, I'm Zachary Krock. This episode was produced by Sarah Lilly and mixed by Jeremy Johnston. We had help from Daniel Morris Rapson There's the assumption that it came from something military related and I have to break their little hearts and be like, no, I just fell off a horse, you know, I'm not that cool. Free Economics radio network, the hidden side of everything