E22_ full
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Alex: [00:00:00] Okay, 

Amy: we're back again, the third episode of mastering Medicare back from Covid. Eventually, I'm gonna stop saying that. Today we actually have an amazing guest, but before I go into that, I wanna make sure everybody knows that we, Alex and I have created an amazing new product. We have been for a long time trying to address issues within the stakeholder community for aging in place.

And we have released a newsletter. It's called Aging Here. And we would like to encourage all of our listeners to subscribe. It's [00:01:00] available@aginghere.com. Alex, anything else about aging here.com. 

Alex: Yeah, so it's, it's really focused on like the business and operations and innovations in the aging in place space.

So, so for everybody who's on the business side of aging in place, that that's our, that's our target kind of audience. And we, we we, we want feedback. Yeah, we want feedback and we want stories. So share your stories if you're doing something cool in that space. Please contact us info@aginghere.com.

Okay, let's get going. Yep. Okay. 

Amy: So today we have an amazing guest and one of the things that's amazing about this is that last week's episode we talked about CPT coding, ICD 10 coding. And so today's amazing guest is Mark Gruner, who is coming to us from Limber Health.

I need to dive into how I met Mark. He is a physician and about, I don't know what you say, mark. About five weeks ago we were sitting at a cafe called Java Nation and [00:02:00] we Just we're sitting near each other and you were having a very lovely breakfast with your wife and your adorable child.

And I was having a business meeting with this really very lovely person who was trying to work on a startup and we kept using the word C P T code and I kept saying, you don't need the C P T codes. Maybe you wanna do this and maybe you wanna do this. And you turned around and you're like, I'm sorry, I don't mean to eavesdrop, but I heard the word C P T code.

And I was like, what? There's a guy who also knows the words c p t code, and we began talking and Mark gave us a lot of information while I was sitting next to him. And it turns out that Mark is not only a physician, but he's also an entrepreneur and also apparently very, very clever because he has created through his experience in pm and r a.

Company and you're gonna tell me how wrong I am and how amazingly off target I am that basically. Works in the R T M marketplace. [00:03:00] And then Mark went on to tell me how he actually created the new C M S C P T codes and for rtm. So it wasn't just that you started a company, you actually created the market.

So that is why we are here and I'm excited to introduce you. So Mark, why don't you go ahead and introduce yourself and give your background and we'll kind of dive in from there. 

Guest: Yeah. Well first of all, I just wanna say, you know, I definitely had a, a part of, of, of creating codes, but it, it, it is throughout the journey.

I can tell you it's a team effort where I was just one of many stakeholders that helped create the new codes. But brief background myself. So I'm a, a board certified sports medicine physician, did my medical degree in b, a focus on value-based healthcare. Worked briefly at C M M I on some innovative value-based care models, and then trained at Mayo Clinic in Rochester, Minnesota.

And we did several clinical studies on the solution that we're gonna talk about which is called Limber, which is a company I created with [00:04:00] my brother. And then those studies helped us work on new c p T codes that we actually did the, we were part of the, the submission working with the AMA Dim Impact Society on creating new CPT codes like you said.

Alex: That is amazing. So, so Mark, tell us about Limber. What does the company do? What's the problem you guys solve and what's your guys' approach? 

Guest: Yeah, so we're a digital MSK solution. Trying to improve therapy adherence for patients suffering from MSK injuries. And so what wait, 

Amy: MSK is musculoskeletal.

Just to clarify for our listeners, cuz Yeah, that's great. Not, I'm, I'm literally thinking Memorial Sloan Kettering. So, you know, we never know. MSK 

Guest: is anything that has to do with orthopedic care, which is knee pain, shoulder pain, and to many providers. We, we say, we say msk, which is a bucket term for the largest healthcare spend in the United States when you look at health service spend.

[00:05:00] So essentially what it is, a patient gets an app. And that app has exercises software that enables your physical therapist, occupational therapist, or physician to remotely monitor how you are doing with your exercises and tracking that through a portal that the provider gets. And all that is being reimbursable where tying the, the care that's being done in the clinic.

With care that's, that's supposed to be done at home, which is the exercises. So patients can be more compliant with their home exercise therapy. 

Amy: So let me, let me go back a little bit to the beginning cuz you know, I always think when you live in that world, you're like, wait, what, what, what? So what you're saying is that a physical therapist might give a prescription, basically like a prescriptive exercises.

And what happens is the patient's supposed to go home from a brick and mortar physical therapy place cuz not, it's not gonna be house calls and. But it could be, and we'll talk a little bit about that. But then they're supposed to do exercises at [00:06:00] home and it is your technology that kind of both encourages.

As well as monitors those at-home exercises and the person that then says, Hey, listen, you should be doing these at home, can then get paid when you do your exercises. I mean, is that basically it? 

Guest: Yeah. Y you're spot on. So 80% of getting a good outcome with therapy is doing these exercises consistently at home, so, If you wanna strengthen the muscles, it takes about six weeks for that to improve.

So you want to create a sustainable lifestyle of doing the exercise at home. So a therapist before technology was giving out a paper printout to patients. Imagine Amy, your mom, and they get a paper printout on the exercises and they're like, What am I supposed to do? What did the therapist say? How am I supposed to do this exercise correctly?

And they forget. And they're, then they're supposed to come back to the clinic, and then they, they forget again, [00:07:00] and then they're supposed to go home and they, they don't have anything to do their exercise besides a paper printout that they end up throwing away after several months. 

Amy: So let me ask another question.

So what is the average age that you sort of envision would be doing this type of thing where the physical therapist would say you, you're gonna get the better outcome if you exercise at home. I mean, obviously that's probably across the board, anybody who's receiving physical therapy services. But in this particular model, this R T M model, this remote, what does the T stand 

Guest: for?

Remote. Therapeutic monitoring. 

Amy: Therapeutic monitoring. What is the average age of somebody who is getting remote therapeutic monitoring? 

Guest: Well, the codes originally went live with Medicare. Mm-hmm. There's now over 45 commercial insurers that cover the codes, but cuz it went live with Medicare you know, our largest age group is, is the patients over the age of 65 over the age of 

Alex: 65.

Mark. Can you talk a little bit more about. [00:08:00] What the all the kind of problems were that you were trying to solve with limber? So you mentioned that there's conf me patients get confused about what they're supposed to do and that compliance is also an issue, but there's other problems too, right? Like people getting surgeries they don't really need and all of that.

Can you talk about all the kind of different value streams that you're trying to generate? 

Guest: Yeah. Great. Alex, great question. So when I was at CM I, which is the think tank for value-based care, I saw that there was a large variance. In the the spend meaning that There's a lot of unnecessary spend for musculoskeletal care.

And it happens early in the episode, and that creates a lot of excess costs downstream, meaning like they go to the ed, they, they get a surgery too soon. And if you can, and there's, there's been several studies that have shown that if you can get patients to do their therapy early and stick to their therapy, you can avoid some of these unnecessary spends.

So one of the when I was originally thinking about [00:09:00] this, It was really frustrating point for me as a physician because I was prescribing physical therapy to patients. Say, go do physical therapy, 12% of people go to physical therapy. Then of the people who do go 30% complete it. So then they come back to, to, to Amy, Alex, me, and I ask them, did you guys do your physical therapy?

And they say, no, it was expensive. It was. Challenging because of taking off time from work or traveling there. And I saw there were so many barriers for, for patients being successful therapy. And then I was like, well, that's really tough because I don't know what the, the next decision to do for you.

If you, if I don't know that you didn't fail conservative treatment fully. I wouldn't wanna order an MRI if I, if I didn't know that, that you didn't at least try conservative treatment. And so that's where a lot of the. The ideas behind limber the company I created really came from. 

Alex: That's amazing.

So [00:10:00] at this, so you identified these kind of different problems and opportunities, right? Mm-hmm. But then the codes didn't really exist, right? The R t M codes didn't really exist. Can you tell us a little bit about that story? About how, like, how does that even happen that you, you know, you help become part of a team to develop new codes?

Guest: Yeah. So when we first we're working with clients. We worked with employers solely based on the business model, but I always wanted to work with providers and in order to, I, I know just from being a provider, and you guys will talk a lot about this today, is you need to have a good business model.

And I knew if there's any way to work with providers, I need to have an ability for these codes to be reimbursed. So I worked very closely with the AMA Digital Health Payment Advisory Committee. Met some friends in DC like Robert Jaron and a few others, and you know, met with the AMA Zach and, and worked on these codes and, and garnered [00:11:00] support from many medical societies and the American Physical Therapy Society.

Alex: But how does that, how does that even start? Like, do you email somebody saying like, I have some new codes for you, 

Amy: or what 

Guest: a light bulb went off? Yeah, so for, for, for, for me it started when I was at Mayo. I was I wanted to know about how to create a new code and there was a physician who was part of the RUC committee.

With the ama and he told me the process of creating a new code in the us. So so I went to him and, and then he gave me a contact to the AMA and I reached out to that contact and that contact I asked him, you know, there are new remote patient monitoring codes that primary care doctors can build that you guys are very familiar with that measure physiological data.

Can a orthopedist or physical therapist do the same thing for monitoring their patients for therapy? And he said, no, you can't do that because it's not [00:12:00] physiologic. And you know, I said we measure outcome measures. We, we measure their their therapy. We track the range of motion, we track how they're doing with their exercises.

He said, you're gonna have to create a new code. And I said, well, how do you go and do that? He says, it usually takes 10 years, and a lot of times it doesn't work. But here's the application and if you wanna submit it, we have a month to to, to submit it. So it was, I think June of 2019 and I put together an application and there were several other stakeholders that were also putting together an application similar we, we band together.

That is 

Alex: so amazing. Amy always jokes with me that like, success in business depends on like two things. One is who you know, and two is the ability to fill out forms. 

Amy: I always say that if you are willing to sit and fill out form after form after form, you will undoubtedly succeed because it is the biggest barrier that they're like, I'm [00:13:00] not doing that.

People always say to me, well, I mean I was gonna do that. And then the form was this thick, so I just walked away. And I'm like, but all you have to do is just fill it out. Flip the page, fill it out, flip the page. So that is interesting. I mean, I'm, I am, as you can tell from the fact that, you know, we continued our conversation after that.

First serendipitous meeting. I, I'm, I'm blown away at the fortitude. That gets you through to that. Let me, let me, I, I always like to go back to like what the primary care provider or a physician or any sort of provider will experience. So I do go back to basics all the time. Mm-hmm. So let's pretend I am a primary care doctor.

And I say to myself, I am going to refer this patient to physical therapy because they have knee pain and they may be on their way to a knee replacement or they have back pain and they may be on their way to a back surgery. But I wanna try something more conservative. When we talk in medicine, when we say conservative, it means we don't jump to [00:14:00] instrumentation, we don't jump to doing some sort of big procedure.

So we opt for a conservative opportunity and we send the. That person that patient to a physical therapist. So the physical therapist is gonna see that patient. Then what exactly happens? They make a decision that they're gonna do x amount of weeks of therapy at X amount of times per week, and then in between they're supposed to be exercises.

Can you walk me through what it would be like if I was a physical therapist working with Limber Health? 

Guest: Yeah, so if you're a physical therapist working for liver health, you know, first of all, we provide risk stratification so you can get a good global picture of what the patient risk factors are when you meet them for that first physical therapy evaluation.

You can know their pain and function outcome scores. On that first evaluation so you can have a better conversation about psychosocial measures, their pain and function severity, so you can approach that eval [00:15:00] when you see that person for that first time in a different way. Then you go through your physical therapy session, you show them how to do several exercises.

You might do some manual therapy going over how the, the calm down, any inflammation that's happening in your, in your joint, let's say for a knee. And then at the end of the visit, you're gonna go to a portal and you're gonna give you, you're gonna select certain exercises that you want the patient to do at home.

And you tell, and, and this happens before any technology ever existed. It was a paper printout. But essentially they would say, we want you to do. You know your knee squats. We want you to do your lunges. We want you to do certain exercises to make sure you can strengthen the muscles in your knee, and we want you to do these consistently at home in between our visits and after the end of your physical therapy episode.

So then they put the patient on those exercises through a portal. [00:16:00] And then within the patient downloads an app. Within 24 hours, our care navigators who are licensed professionals reached out and they check in, they go over the goals of what the, the, the therapist wanted. Make sure that patients understand what was going at home.

You know, the patient's now at home. And go over what their, their journey's gonna be like over their entire physical therapy episode. And then we're remotely monitoring those sessions in between their visits of the exercise they're doing at home and making sure that they're consistently doing their exercises until they hit functional maximal recovery in their injury and they're able to return, and then they can have exercises that they want to do at home afterwards.

At the same time, we're tracking their pain and function. So your, your provider knows just like blood pressure Amy and Alex, you can track ob objective numbers to know if your patients are improving and if they're doing their [00:17:00] exercises, so you can make different changes about what's going on in their care.

So I'm a little 

Alex: confused. Mark, explain to me like who's, who's buying your solution? Like who's, how do you guys get paid? And, and like is who's actually the user other than the, on the, who's on, who's the user On the provider side or on the professional side of, of your solution? 

Guest: Yeah, so the, our, so the people who are, are paying for us are the providers.

And so we invoice them based off of essentially billable milestones that we've achieved. For remote monitoring. And so if we achieve certain points of, of monitoring, we invoice for our services to the provider and the patient is using that. 

Alex: Got it. Okay. So just let me kind of recap that, make, tell me if I got it right or not.

So s and actually before we do that, can you clarify [00:18:00] what sort of providers can bill rtm? Because I think it's different from RRP m right. 

Guest: Yeah. So there, there's some really big differences. The what you, one of the biggest differences is that, In R P M, it's billed by physicians, nurse practitioners, and they those are the, the main people that can build those codes.

R t M can be billed by physicians, physical therapists, occupational therapists, speech therapists, or physician assistants. This is huge, 

Amy: by the way. That's huge. That's huge. I'm sorry I had to interrupt. It was like one of those moments. Sorry Alex. It was, it's amazing. I really wanna say this out loud because this is actually kind of profound to me.

You know, we spend a lot of time talking about in the part B world, who are, you know, who can bill part B, and we always talk about nps, PAs, MDs, dos, that type of thing. But physical therapists obviously are doing work in the Part B space, and they can build these codes. And that [00:19:00] to me is actually, that's like a market maker.

I mean that like cha can change the calculus for how much money a physical therapist can make. I'm, I'm guessing, right? I mean, there's gotta be an enormous amount of money now that a, that a physical therapist could potentially make. By being able to then all, not only just having good patient outcomes, but they actually can increase their day over day revenue.

Guest: They can I usually like to, to always say that this is not something, you know, just to make money, but Sure. I do think that what the, the most important thing is that this is a way for them to know how their patients are doing for their, their therapy exercises. And, and one of the important things is that, Physical therapists and occupational therapists spend so much time with their patients, so they build a relationship and being able to connect what's happening in the clinic with what's happens at home, it's just making that relationship stronger, which is gonna help get a better outcome.[00:20:00] 

Yeah. So 

Alex: let me recap that. So Mark, so basically providers the kind of typical providers like physicians, PAs, nps, Plus these physical therapists and other sorts of folks can bill the r t m codes. So in the, in the fee for service kind of model, they, they're billing the r t m code and getting paid typically.

What, like what's the typical range? Like per, per member, per month. 

Guest: What they, what they'll receive? The what they'll, what they'll receive. Yeah. It all depends on, on if billable milestones achieve. Okay. But the codes are exactly similar to, to rpm. They're, they're identical. And they're very similar in valuation purposes too.

Got it. 

Alex: So let's call it, I don't know, a hundred. Dollars pm pm plus or minus. So they're getting reimbursed something in that range, and then they're paying limber and similar companies a lesser amount, presumably to support the [00:21:00] program with both technology and the clinical. Services, right?

Like, and the time that's spent with the patients to reach those milestones. So that's the kind of general fee for service model, 

Guest: right? Absolutely correct. But these codes were not just made to be billed for fee for service. They were, were were designed and the reason why I was so excited was billing for the services, which I think are really important, the technology and care navigation services.

So we can build and have a glide path towards innovative alternative payment models to address those, those high costs that we were talking about earlier. Yeah. So 

Alex: that's, I think that's the really kind of interesting and amazing piece. So talk to us a little bit about what that glide path looks like.

How does how does this work in a, in a value-based model, and how does your company work in a value-based model? 

Guest: Yeah. So if you think about you know, what are the things to be really successful in value-based care? What are the tools that you need? You need to be able [00:22:00] to track outcomes really well, so on your entire population so you can know how they're doing.

Connect care that's happening in the clinic with connect connecting care at home and, and coordinating care across the entire episode. Making sure that patients don't go to the ED for low back pain. For example educating patients not just in the clinic, but also at home about their conditions so they can have well-informed choices about what's going on.

And using digital technology to try to improve therapy adherence. And so by doing all those things, we think we can make a huge impact in lowering total cost of care. And so essentially what it works is in, there's many different value-based care models, but one of the models that we are going live in the state of Maryland is a total cost of care shared savings model.

With MSK conditions, starting at the physical therapy evaluation. So they, they can use these RTM codes, [00:23:00] they can bill for these services so they can have these tools to help them be successful and win in a total cost of care shared savings model that is going live for any therapist, physician, with therapist in the entire state of Maryland starting in January, 2024.

Wow. So 

Alex: let me make sure I understand. You're saying if you're, if you're a physical therapist in the state of Maryland, You could use these, you could use the limber platform and Bill, bill and get reimbursed for rtm. And potentially on top of that, you might get some shared savings dollars too. 

Guest: Yes. With, on total cost of care with specialty program called equip.

And so th this is not just for physical therapists because I'm trying to be as inclusive as possible. Sure. This is for physicians. That work with physical therapists in a multidisciplinary setting. This is for hospitals that, that work in a multidisciplinary setting or the individual therapists, but anyone can, they see the patient, they [00:24:00] can use these RTM codes to monitor how their patients are doing throughout the episode.

And if they, they show success, they show that we can lower total cost of care for patients, provide really good outcomes, which we track through our software. So, Then you can actually earn additional savings on top of the R t M codes that will help the payer Medicare in the state of Maryland and also help the patient have more affordable healthcare.

Alex: Is this Maryland program just for Medicare patients or is this all payers? 

Guest: This is for Medicare patients only. Got it. 

Amy: So if I was a physical therapist or a physician, how do I sign up for this? I mean, this is always where I like to go is, you know, you hear about this sort of very broad, strokey amazing stuff.

How exactly would somebody sign up to participate in this? Or 

Alex: in other words, where's the form? 

Guest: So 

Amy: www I can help. Yeah. 

Guest: Two different things, you know, for, for if they [00:25:00] want to do the remote monitoring track outcomes use the tools that we have at limber. That's, that's very easy. It's a contract that we sign.

We help get a, a Care navigator with your team. Depending on your size, it might be multiple care navigators. And it usually takes a month of training the team. And then we, we can enroll patients pretty quickly depending on which insurers are covering the codes. And we work pretty closely with that.

That's on the limber side. If you are any type of therapist or physician that's interested in MSK models and addressing total cost of care, You can participate in a program called Equip that's run by the H C R C and the state of Maryland. And it's very simple. You just go to crisp, which is the h i e meeting health Information Exchange which essentially looks all at all the data.

They, you, you'll tell certain people that you want to participate. They add you as a [00:26:00] provider. You designate which entity that you want and what model you wanna participate in. And then that model goes and gets blessed by C M M I. And benchmark is created for that individual provider on what their total cost of care spend is.

Alex: That's amazing. It's really cool how in Mar Maryland with the whole global budget model and the total cost of care and crisp, how all of these things fit together like a puzzle. That is really amazing. 

Guest: I, Alex, I can tell you I've been working on value-based healthcare for 15 years and I've never been more excited than the innovation that's happening in the state of Maryland because, To create new models, it's very challenging.

And you need the government to participate. Yeah. And so if you're a physician, you could go through something called the Physician Technical Advisory Committee, which is called the ptech, which has not approved the model to [00:27:00] date. Or you could go through the state of Maryland. And, and this, the partnership between C M M I, the Center for Medicare and Medicaid Innovation Center and Equip, have enabled a lot of innovative specialty care models that could exist.

And this is a a great place for us to, to innovate, think of new models for savings and, and show are these models actually bending the cost curve for total cost of care. Would you 

Amy: say that the state of Maryland is more like a playground for types of this type of innovation than other places?

Because it's, it's interesting what you're saying actually. 

Guest: Absolutely. There's no other place in the United States. That this type of innovation exists. You do not have models that are existing in the state like this. And I think, you know, every single state in fact, change Healthcare had a, a really good article that, that went through all the value-based care models in all 50 states.

I'll have to send it to both you guys. Oh yeah. Oh yeah. [00:28:00] They, they're all very, you know, they're either accountable care organizations or they're Patient-centered medical home models but nothing in the specialty care space. And, and what what's really innovative about the state of Maryland is they have many different procedural and con chronic conditions.

And now physical therapy, alternative pain payment models that are really revolutionary, that are connecting the primary care doctor. And the specialists together so they can address total cost of care. Wow. 

Alex: Where can folks go to read and learn about all these different innovations in the state of Maryland?

Guest: If you Google search Maryland, E equip, eq, ip you can learn about the Maryland equip models. And learn about the many different type of models that they have. From everything from a knee [00:29:00] replacement to oncology, specialty care, to M S K, which is our MSK physical therapy model to kidney care. So you can imagine every single condition, there's over 50 different specialty care models that exist and are being managed and administered by the state of Maryland.

I'm, 

Amy: I'm totally blown away. And it's funny because I would, I would venture to say that, you know, there's, I. In my previous life when I was doing house calls, I really took pride in understanding a tremendous amount about some of these things, but always felt fairly handicapped when the terms value-based medicine came up because in the state of Maryland, there are so few Medicare Advantage plans, but in some ways the, the state has figured its way around that by continuing to have.

Original Medicare, but with all of these cool add-ons and cool opportunities, is that, does that sound about 

Guest: right? I think [00:30:00] that that is, is spot on. A, as we all know, Medicare Advantage is growing. It's 50%, but just from my experience being a practicing physician, also, there is a large amount of Medicare beneficiaries, and I think it's a combination of.

People really love their red, white, and blue cards their Medicare cards, and they really like some of these innovative value-based care models where you're seeing providers really not just look at a patient and saying, I'm seeing you for 15 minutes. I'm now in charge of your life and helping you be successful in your journey to recovery over an entire episode.

And so that type of mindset, which is starting to exist in the MA market, where you're in charge of, of, of someone's care over a period of time is happening with the red, white, and blue card. 

Alex: Mark and Amy, I'd love your guys'. Take on the f the following. [00:31:00] If I'm a patient, h it seems like all of this risk taking is happening really without my knowledge.

Sometimes without, maybe even without my like overt consent, I'm like, I'm not even sure, like, how, where's the patient in all this? How does the patient know that somebody's like taking risk on them in one of, like, in one of these 

Guest: models? That's a really good question. So, first of all, if they wanted to do remote therapeutic monitoring, we always get consent agreement.

We go over that with the patient. That's required for any remote patient monitoring R P M or remote therapeutic monitoring services. And if someone says differently, then you should contact representative right away. Secondly, when it comes to risk-bearing things, I don't know the exact definition of, of where the patient knows what's going on, but that's something that could be brought up with the state of Maryland.

But most providers should disclose that the, that they are in a, a [00:32:00] value-based care diem, I'm assuming. But I know that we, my orthopedic group, we participate in. Equip models for bundle replacements for knee and hip replacements, which are some of the earlier specially value-based care models.

But that's a really good point and I'm, I'm not sure if I have the answer for that, Alex. 

Amy: So, Alex, I'm gonna, I'm gonna, Take from Mark and just keep going here. So when I was doing house calls, I was part of the MD P C P and we had to inform the patients that we were a participating provider with the MD P C P.

Did it spell out exactly in that particular letter that, you know, we were going, if we did a certain amount of chronic care management and this and that and the next thing that we would have a value-based, you know, like there's a value-based. Incentive for us to do A, B, and C. No. But we did inform them that we were part of that and we gave them information about the M D P C P program so they could look it up.

But I can't imagine that most patients. Did try to figure out [00:33:00] actually 

Alex: really cool as a patient to be able to just go to some like simple website and know like, who's making money off of me and how much, right? Yeah. Well, I dunno. I think that'd be cool. So, so, so Mark, let's say I'm a listener here and I have like, I, I feel like limber would be great for my dad, for example.

Is there a direct to consumer model for 

Guest: you guys? We don't offer a direct to consumer model to date. You could go to a provider group that we work with, whether it's a physician or a PT or an ot and, and work with that. But we don't have a direct to consumer. But essentially, once a provider signs you up, then you will get an email on how the download and.

Get instructions. And so the best way is to participate one of, with one of our providers who we're trying to work together with, to empower them with digital technology and tools to help them be [00:34:00] successful in the next generation of value-based care models. 

Alex: So is there an easy way for folks to know which providers are using your system?

Guest: Yeah. There, there, there are, there are. So we're in 40 states. We have different provider groups. But just so, you know, there, there are several that that we work with. And depending on where you are located there's a good chance that you might be seeing us, depending on if it's a PT group or an orthopedic group.

Very cool. 

Amy: Let, let me ask a couple of sort of down to earthy type of questions. Number one is, what is the general cost of a knee replacement? Like, how much does a knee replacement cost? And if. That's considered to be, you can offset that cost by continuing to be a compliant patient and doing your therapy or at least delay it.

What does that look like from a cost 

Guest: perspective? Yeah. Well, you know, first of all, some need replacements and hip replacements are necessary, but not all of 'em. But they can be anywhere between. And including spinal fusion and [00:35:00] other conditions, anywhere between 27 to 50 to sometimes 70,000. It, there's many variables that, that play a factor into that.

One, if it's done in the hospital versus an ambulatory surgical center makes a, so the site of service is a, is a, a, a big factor that pla plays into that the second most important thing, Is the, the rate that's being negotiated with the insurer on, on what's the price for, for that knee or hip replacement?

For example did I answer your question, 

Amy: Amy? It does. So I'm just gonna kind of like, think about this as if I was Medicare. So. One of the reasons it seems like they're incentivized to really want people to utilize these codes is that if they can offset a single, single surgery, they may be paying $1,200 in R T M, but they may be saving $50,000 on the backend.

Is 

Guest: that right? Yeah. I mean our, our, cause our our numbers are a lot lower for RTM because it's a shorter [00:36:00] episode. Right. So it's significantly lower than the, than the Yeah. From an episode. But yeah, there's the surgery that, that can be avoided hopefully, and save, there's unnecessary imaging, so there's very good studies that if you don't do your therapy and there's a lot of insurers that say that you have to do therapy in order to get an mri.

But if you get that mri, There is a high chance that you go on to more expensive services, meaning like injections, surgeries, opioids, that, that really make up a huge amount of cost in addition to the surgeries. And to give you an example, and everyone on the show should, should hear this out, if I do an MRI on a patient who is 50 or 60 years old with low back pain.

I will always have something that shows up on the imaging of degenerative disease. Yeah. So, and as a patient you hear something that is wrong and there's injured. You could have no numbness or tingling or radiating [00:37:00] things down your legs that it are things that, that are urgent for fixing your back.

But have all these things that show up on your MRI and you go and get more and more services that don't actually provide you the tangible benefit that you need. And so I call that two different things that are, can be saved by just doing therapy. And a lot of payers have recognized that. And so in order to order an mri, sometimes they actually require six to eight weeks.

That's 

Amy: fascinating. It's 

Alex: like, I call that, I call that a therapeutic m r i. It's validation, right? If you show your spouse, you're like, this is why I need to like, veg out in front of Netflix. Look, look, I have a little bit of DJ D in my spine or whatever. 

Amy: But that, that's profound. So over time, with enough data, people realized that the more you do, the more you do.

Yeah. So that the idea of conservative treatment. Actually becomes so important for the entire [00:38:00] societal approach to healthcare in some ways, and it's not just to be big jerks. In some ways it may be saving morbidity, so, As well. Correct? Because the more you get instrumented, the more you get instrumented, the more you get instrumented in some ways, correct?

Oh 

Guest: yeah. I mean, how many, absolutely. So I'll give you an example. Let's go back to the back pain. We know that if you get one spine fuse, so if you don's say they, they, they, they say that you have got really bad degenerative disease and they, they say they, they need to fuse the spine. You can't move that, that, that part of your body as well anymore because it's fused together.

So what happens is they call this adjacent, Es. So the disc above and disc below actually degenerate. Depending on the literature, it can be 2.5 to 5%. Each year that it gets worse and worse and worse, so you have a chance of getting another fusion. And between that anesthesia that you, that, that can, can happen and the fact of [00:39:00] having more surgeries that could fuse your entire spine, it really be can cause morbidity for you.

Amy: Okay, you'd already sold me. I'm not gonna tell everybody about limber, like I'm already gonna tell everybody, but the idea here is that you want to profoundly change the trajectory of a patient through the healthcare system in some ways, not just to make money. Obviously, you know, you even though I started there and not just because it seems like, you know, like maybe this, I can figure out what's going on with that person at home, but really it could actually save them a.

Significant long-term consequences that maybe not everybody understands, and perhaps not even our physician colleagues understand. You 

Guest: know, Amy, Alex, today, I, I, I really want to tell you, like I, I, I firmly believe you need to have a good business model or it, it just doesn't work in our system. That that is pri priority number one, but my passion for this, Is because it's the right thing to do and it [00:40:00] really can help save money and provide patient outcomes.

It's a real win-win situation where if you can help patients early on in their episode, do their therapy, make sure they're successful with their therapy, help providers understand how patients are doing. And be able to, to track and coordinate care better. You have a real good shot to avoid some of these unnecessary spend and, and prevent some complications that could happen from some unnecessary hospitalizations and surgeries.

Alex: Yeah. I wanna underscore, I think what is a really important point here, which is. I don't think there should be any shame in understanding how the money flows and that there's a positive business model here because look at where we started, right? We started where basically orthopedic surgeons could only get paid or get paid the large box if they operated, right?

So now we end up in a situation where, Too many patients are getting operated on for con, [00:41:00] for conditions that actually don't benefit from surgery and actually just introduce a lot of risk, right? So in order to change that, you have to create a financial model where people benefit from doing what's right.

And that's really what R t M is, is creating a business model where, where the financial incentives are aligned to do what's actually right for the patient. And I think that's really 

Guest: awesome and wonderful. I, I, I, I just echo exactly what you said, Alex and I, I completely agree with you. 

Alex: Awesome. So so let's try to wrap it up.

Mark. Are there any other kind of final thoughts, anything else you wanna share and how, how can people find both you and 

Guest: limber? No, I, I, I am very appreciative of Amy and Alex. I think you know, you, I think the world of you guys and how how helpful you guys are to startups like myself and look forward to, to collaborating and working closely and hopefully having you guys over for dinner at my house soon.

Yeah. Yes. [00:42:00] 

Alex: And what's the limber website? It's 

Guest: limber health.com. 

Alex: Awesome. Fantastic. And remind everybody, please join our Aging Here newsletter, aging here.com. If you have any stories to share with us, email us@infoaginghere.com. Thanks a lot folks. I.