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CHAPTER 6: INSURANCE AND COSTS

No discussion of treating any health problem is really complete without investigating insurance coverage and payment / cost issues. Many times when people call my office about scheduling a spinal decompression consultation one of the first things they ask is “Is it covered by insurance?”. Now, that might at first seem to be a pretty good question, but when it comes to treatment for spinal disc problems, insurance coverage actually has little to do with what the out of pocket costs will be.

I may be wrong about this, but I strongly suspect that when someone asks about insurance coverage, what they really want to know is how the out of pocket cost for my treatment program compares to the out of pocket costs for other treatment options they might be considering. If the concern is really what the out of pocket costs are, simply determining what is and isn’t covered by insurance can be very misleading.

To illustrate this, let me use the example of the treatments I use in my office as compared to the other options available for people with disc problems. Treatment programs based around new technological advancements such as spinal decompression, like the program I use in my office, are primarily intended for those people who have not had good results with, or for some reason cannot use, other treatments like oral medication, chiropractic, physical therapy, cortisone injections, etc..

For such people, their options come down to either spinal decompression programs like mine, or surgery - or simply living with the pain. And although living with the pain may not cost anything in terms of out of pocket payment for treatment, it can cost a lot in other ways, both financial and non-financial. Not to mention the fact that most disc problems get worse over time and what someone may be able to live with now can turn into something that they can’t live with later. So, this brings us back to the options of spinal decompression and surgery. If we compare overall effectiveness of spinal decompression to surgery, spinal decompression is the hands-down winner from that standpoint, but what about cost?

Well, because spinal decompression is still very new, it is usually not covered by insurance at present. Now, some of my spinal decompression program consists of treatments that are typically reimbursed by insurance, but spinal decompression per se is usually not covered. Surgery is of course an established treatment, and it is usually covered by insurance. Based on that information alone, one might assume that the out of pocket cost for spinal decompression will be more than for surgery. But that is usually not the case.

Let’s look at the out of pocket costs for spinal decompression and for surgery. To keep things simple, let’s assume that you have an insurance policy that covers nothing (0%) on a spinal decompression program, but it covers 90% for any other treatment, including surgery. Now, 90% coverage is pretty unusual these days - coverage is usually less, and there’s usually a deductible before insurance kicks in, but let’s use that 90% coverage number with the realization that most insurance coverage is probably not that good.

Let’s say that you needed a moderately intensive spinal decompression program, costing $5,000 (depending on the case, treatment costs range from $2,000 to $10,000, but most cases in most parts of the U.S. fall in the $5,000 or less range), and since we’re using an example where none of that is covered by insurance, your out of pocket cost would be $5,000.

So, let’s now look at the surgery option. With 90% insurance coverage, that’s going to cost a lot less out of pocket, right? WRONG!!!! A moderately complex spinal surgery costs in the neighborhood of $50,000 (and that’s just the surgery, it doesn’t include post-surgical follow-up and rehab, which will usually add another several thousand dollars to the price). So, with 90% insurance coverage, you would pay 10% of that $50,000, which comes to $5,000 - the same out of pocket cost as for the spinal decompression program. If you had insurance with the more typical lower coverage levels, your out of pocket costs for surgery could be considerably higher (maybe double or triple!). The other thing to be aware of is that out of pocket cost for surgery may not be revealed to you until a surprise bill comes in the mail - perhaps when you are least prepared for it. And remember, even though we used an example in which there was no coverage for spinal decompression, in most cases there is some coverage for part of the overall treatment program.

As mentioned earlier, in terms of effectiveness, spinal decompression is the hands-down winner - better than 80% effective for most situations as compared to about 50% effectiveness from surgery (with about 20% of cases actually getting WORSE after surgery). In addition, spinal decompression is considerably safer than surgery, it is comfortable, and there’s no long recovery time as there is with surgery. If you’re still working for a living, you can continue to work while getting spinal decompression treatment. With surgery, you will likely miss at least a few weeks of work (for “minimally invasive” surgery), and chances are you’ll actually be out of commission for a few months. So, with out of pocket costs being about the same for the respective treatments, you potentially get a much greater value for your money with a spinal decompression program than with surgery.

When you see the big picture, I think you can appreciate how judging a treatment solely by whether or not it’s covered by your insurance can be a very costly mistake, in terms of both money out of your pocket and results.

Now, I’m sure that there are some people reading this who have decided to live with the pain rather than face paying for treatment of any kind. If that’s you, I hope you’ll forgive the bluntness, but you need to face the fact that you have a serious health problem, and as with any serious health problem, it’s probably going to eventually FORCE you to invest some time, money, and effort to handle it.

Most people can get away with “living with the pain” for a while. Unfortunately, disc problems progress in most cases. Not only does this mean increased pain, but neurological damage can begin to occur.

With low back disc problems, this can result in things like loss of leg muscle strength and control, loss of bowel and bladder control, and loss of sexual function. In the case of problems with discs in the neck, this can result in loss of strength and coordination in the arms and hands, loss of balance, and severe headaches.

So, when things get bad enough, there’s a lot more motivation to address the problem. Be aware though, that the longer you put off doing anything about the problem, the worse the problem can get, the fewer treatment options you will have, and chances are, the more costly the treatment will be - whether or not you have insurance.