October 8, 2025 • 29 mins
Dr. Sandeep Rao brings the borderland the latest information in healthcare, medicine and technology. He considers himself a hacker in the positive sense, using his intimate knowledge of the medical system to break down some of the barriers to accessing new medical technologies and information.
For more information call Dr. Rao's office at 915-500-4370 or email Rao@medicalhackers.com
Be the first to hear the show in News Radio KTSM-AM Saturdays at noon, an iHeart station.
For more information call Dr. Rao's office at 915-500-4370 or email Rao@medicalhackers.com
Be the first to hear the show in News Radio KTSM-AM Saturdays at noon, an iHeart station.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Good afternoons of the weekend year the heart of the
dusty Choo desert in the West Texas, and you're just
maintain two the medical hackers. However, he may be tuned
in this week, and I'm your host, doctor Sandy Browt.
I'm here to bring the borderland the lace information in healthcare,
medicine and technology on this show. I consider myself a hacker,
(00:25):
a hacker apologicians, a hacker using mind intimate knowledge of
the medical system, health of breaking down from the bear's
accessing new medical technologies and current healthcare information. So it's
just myself in the studio today and Namber's producing us
always exactly. Now. I don't know if you remember this,
z Amber, but on a prior show, I discussed patients
(00:49):
who came in with shoulder pain and how I approached
them from two different standpoints. On that show, I think
we had Juni as a He was also on the show,
so I remember discussing this with him, and I wanted
to do a follow up because I've gotten a question
about why did I offer different treatments for patients who
(01:12):
have very similar symptoms. So both these patients have or
had at this point, they had shoulder pain, and I
decided to offer them two different treatments. One was a
point of attack was going after the nerves that's supplying
the shoulder that gives rise to a lot of the
(01:37):
sensation that you get in the shoulder and the upper arm.
The other patient, I attacked that problem from the standpoint
of going after the blood vessels that supplying the shoulder joint.
Now the PostScript to this thing is that both patients
actually got good results. They were able to get improvement
(01:59):
in their pain. Mostly they're having a lot of pain
at night when they were sleeping, they had shoulder pain,
that pain whenever they try to initiate movement. But both
these patients got good results. But the question that is
often asked of me is how do I decide what
treatment to offer a patient. So there's a lot of
(02:22):
different things that go into it. Sometimes it's based on
MRI findings I might see. Sometimes they might be based
on an X ray finding. Sometimes it's based on if
they have a definite known diagnosis of what we call
frozen shoulder's called adhesive capsulitis. That's a sort of an
inflammatory process that's been involving the shoulder capsule that might
(02:43):
point me in a different direction as opposed to another
patient who just had no significant loss in range of
motion but just had an ongoing shoulder pain. So there's
definitely a significant component to it that involves the patient's
clinical presentation. But unfortunately, another thing that plays a significant
(03:07):
role in how I decide to treat a patient, unfortunately
is the patient's insurance. And I want to kind of
get into that because there's actually some changes happening with
one of the insurances that I actually gives me the
most freedom to treat patients. Okay, So the freedom that
the insurance that gives me the most freedom in the
(03:28):
most leeway, and I can say, you know what, with
you came in, I can offer you pretty much anything
that's available to us. Is actually Medicare. Okay. That's that's
the government insurance as a federal government program that covers
patients who are sixty five and older, and the benefit
of having Medicare when a patient comes into me, which
(03:49):
is just straight Medicare, I'm not talking about any of
these what we call Medicare replacement plans. So a lot
of these insurers take like your private insurance, like a
signal or human or United They all have gotten into
this business of called Medicare replacement plants. So what that
means is you may be eligible for Medicare based on
(04:12):
your age, based on those circumstances, but they essentially act
as a buffer, and unfortunately that actually prevents me from
offering the full range of services because they will then
you know, be able to we have to now go
through something called prior authorization. Meaning imagine you came in
(04:33):
Amber and you said, hey, I have an issue involving
my knees. Okay, I just have knee pain. I ideally
would say, you know what. I see their symptoms, I
see what you're experiencing. I'll say I think treatment A
is the best treatment, and if that fails, I'll go
with treatment B or C. Now I can usually do
that when I don't have much of a restriction from
(04:55):
a prior authorization standpoint, when I don't have to run
my medical decision making past some insure and I can
offer that I can do that now Medicare has provided
me that luxury. If you're a patient on Medicare. Now,
if you're a patient who has some of these private
insurance plans, they tend to offer hurdles where I have
(05:15):
to now go through their prior authorization, meaning I have
to now ask them can we offer treatment A, or
they'll just say, you know what, they'll they already have
a policy saying we don't cover treatment A, you can
only provide treatment B.
Speaker 2 (05:31):
That seems like it would be very frustrating because I've
known you long enough to know that you really care
about your patient's health and like for you to have
to go through those channels, you know when you know
what would work best. It just sounds frustrating on the doctor's.
Speaker 1 (05:45):
Oh for sure. So this is something that actually affects
a lot of doctors. So now you might remember back
in I suppose is maybe last December when we had
the entire the the United Healthcare CEO got gun down. Yes, yes,
so that actually brought about a decent amount of changes
(06:05):
because that the entire reason why the he did it,
Luigim Mangoni. You know, his ostensible purpose was that he
was didn't like this entire culture of deny, delay and deny,
which is what a lot of insurance companies do, which
is what they try to do is they will you know,
(06:26):
just automatically deny requests or what's happening increasingly is a
lot of these insurance companies are using AI, artificial intelligence
to automatically deny deny like keywords or exactly. And so
so what they did a study here pro public that
did and they looked at a two month period of
time at doctors who were reviewing these claims at SIGNA.
(06:49):
So the amount of time they spent on average for
SIGNA per case, the amount of time on average they
spent was one point two seconds because they had already
we had this dashboard of the AI had told them
this is not going to meet the criteria. That's not
gonna meet the criteria, so they can just immediately deny
a lot of these these claims. And so usually they
(07:14):
found that, you know, these AI tools increase prior authorization denials,
and you know, obviously by getting more denials that sort
of now we have to as physicians, as clinics, we
have to appeal them. And so there's a long process
that involves appealing these these cases. So and there's this
(07:35):
Law journal article that came out which looks at these
appeals and the algorithm that goes through it. And what
they've found is that sometimes these AI algorithms. What they
do is they look at patient's life expectancy. So what
they'll say is if a patient is expected to die
within a certain period of time. They really rely on
these algorithms because what they have found is that as
(07:57):
time passes, we have to now force to submit an appeal,
and that actually, unfortunately increases the chance that the patient
will die during that period of time, which point they
may never have to pay that claim. So these are
all things that we have issues with. Now here's where
it is going to become more frustrating for me, because
(08:18):
this news just came out. Medicare, which was the insurance
of choice for a lot of US docs, is now
starting in January one of this upcome here January one,
twenty twenty six, running all the way through twenty thirty one.
They're doing a pilot program which they are now going
to launch a AI algorithm, an artificial intelligence algorithm to
(08:44):
look at a lot of these services. And so two
of the services are actually that we are listed are
services that I offer. So part of what I do
is I said to nerve stimulation, So they're looking at
electrical nerve stimulation, which is one of the treatments that
I had to offer this patient. Yeah, what a lot
of success for pain, shoulder pain, back pain. But that's
(09:04):
a federal expansion into this entire area of prior authorization.
So unfortunately, now something that we never had to think about,
which was having to get prior authorization, now we're gonna
have to go through prior authorization. And just you know,
this entire prior authorization program does not cover the entire country.
It only covers these following states Arizona, Ohio, Oklahoma, New Jersey, Washington,
(09:28):
and Texas. So now it's definite gonna affect me because
I do have practice that covers Texas and Arizona. So
this is gonna be something that I'm going to be
seeing and looking at very very closely because I'm now
concerned that some of a lot of these patients that
I would have gotten authorization for these treatments, I'm not
(09:49):
going to be able to treat them, or at least
now it's going to be posing additional hurdles which could
possibly cause unfortunately irreparable harm and maybe even and death.
You know that that's that's certainly they the thing that
we're trying to avoid here. So just something to know
this whole program, if you want to read more about
it's called the pilot program is called WISER. That's what
(10:13):
they've they've labeled it. WISER stands for Wasteful and Inappropriate
Service Reduction, so w I s e ER. That's the
name of this AI algorithm that they are now going
to implement for some medicare services, and they're also going
to apply it to ne arthroscopy. So a lot of
(10:34):
patients have knee pain, patients who have need skin substitutions
for wound carry on another area that I cover. So unfortunately,
there's going to be a lot of coverage of this
unfortunate plan into my clinical space. So I'm sure I'll
have more information for you going in the future, but
we'll take a quick break here in the Hackers and
go in a little bit different direction.
Speaker 3 (10:54):
You're listening to the Medical Hackers with doctor Sandy brow Board,
certified vascular Intervtwist bringing you insights on treatments for common
medical problems on news Radio six ninety KTSM. For more
information on the issues being discussed, or to contact doctor
Raw call nine one five five hundred four three seven
zero or by emailing Raw at Medical hackers dot Com.
Speaker 1 (11:21):
All right, back here on the Hackers doctor rau here,
I want to talk about a drug that's rapidly growing. Amber.
So the fifth most prescribed drug in the US in
twenty twenty four was a newer drug. It's not a
newer drug, unfortunately, that's actually a drug that's been out
for a while while, but it's actually significantly jumped into
(11:41):
doctor's arsenal. And that's a drug called gabapentin. I see
a lot of patients for on it. And it's a
generic drug, so it's not some drug that is very costly,
but it's a drug that's actually it's now jumped from
being in about twenty ten, about fourteen to fifteen years ago,
(12:03):
about six million people in the US took gallop pen,
but now that's jumped all the way to sixteen million people.
So it's a very very common drug now. And especially
if you're like me and you're a doc or a
practitioner in the space where you treat a lot of
patients who are chronic illnesses, chronic pain, this is a
(12:23):
drug that is very very frequently seen.
Speaker 2 (12:27):
Is it a pain killer?
Speaker 1 (12:28):
So it is a drug that is actually approved specifically
for seizures. It's an anti seizure drug and it's designed
to go after something also called post herpetic neuralgia. Those
are the official indications, So that means patients who've had
herpes related illnesses, who've developed neuralgia, meaning nerve related pain.
(12:50):
It's a pain. It's a drug that goes after nerve
related pain. Now there's also an approval for patients who
have restless leg syndrome, so patients are typically they have
just constant need to move their legs for whatever reason.
I see a lot of those patients as well. And
these drugs, even though there are very limited indications, which
(13:11):
I said just those three indications of the main things
that people are officially treated for, they have now become
widely prescribed for a wide variety of diseases in the
pain space. For patients who have neuropathy, which is what
I see a lot of patients who have a lot
of numbness and tingling in their feet and their hands,
(13:33):
often relate to diabet betic complications. Patients who have chronic
low back pain. It's frequently prescribed for these patients. But
the reason why this comes to me is a lot
of patients want to get off this drug. Okay, a
lot of folks don't like this drug. There's a lot
of common side effects with it. Patients who have drowsiness, dizziness,
(13:57):
blurry vision, double visionicult to coordination, concentration, And in twenty nineteen,
the FDA actually came out with the warning saying that
there are serious breathing problems with patients who take gabapentin
or the other drug in this space pregabble in Lyrica
(14:18):
with patients of underlying respiratory illnesses. So, if you have
an underlying asthma or COPD or emphysema and you're taking gabapentin,
these drugs can actually depress your central nervous system, meaning
your ability to breathe. So, especially if you're an older individual,
which is what a lot of these patients are on,
we're seeing a lot of side effects and so a
(14:41):
lot of patients come to see me because they want
to get off this drug. And that's where a lot
of my treatments come into place. So a lot of
my treatments, especially for patients who have low back pain
or patients who have neuropathy in their feet, I do
procedures involving nerve stimulation minimally invasive procedures where I go
(15:01):
in and put tiny little leads electric wires either near
their knee joint or near their back. And what I'm
just what I'm trying to do is I'm trying to
stimulate the nerves in the back or in the in
the lower extremity, and I'm trying to have different signals
(15:21):
replace your pain signals that are traveling on those nerves.
Speaker 2 (15:27):
And I would think that that way would be more
targeted than just taking a medicine exactly.
Speaker 1 (15:32):
Now you might be wondering what do I do with
this drug? Do I prescribe it? In fact, what you
might be curious to know is this is actually a drug.
Despite all these problems that we have with these with
this drug, despite all the complaints, It's actually a drug
that I prescribe and have to prescribe it unfortunately quite frequently.
(15:53):
Now you may be wondering, why do I need to
do that? Why is this drug at all these negative
things about? Why do I have to prescribe it? Now?
Unfortunately a lot of insurers require that patients have tried
these medications and failed these medications before we can offer
(16:14):
them the definitive therapy. So that's the reason why I
have to do it.
Speaker 2 (16:17):
How long do they have to be on it before
insurance is like all right, try something else.
Speaker 1 (16:20):
Yes, So I have tried a variety of different things.
So the official recommendations from some insurers is you need
to try it for least three to six months. Okay, Now,
some interurs I've seen, you know, they might I can
put them on for a month and then once the
patient has the side effects and then maybe I can
get them off it. But usually they want me to
(16:41):
try it for a certain period of time. Now, most
patients who come to see me, they've already been put
on this drug by their primary docs. So actually primary
care docs and nurse practitioners are actually the single most
common prescribers of this medication. So that's because it's hugely
considered a front line medication sort of like a It's
(17:02):
something that the gatekeepers who see these patients should ideally
put the patient on and so hopefully that once they failed,
then they come to see me. But unfortunately, I have
to try these medications first, have you fail unfortunately experienced
these bad side effects, and then at that point then
(17:24):
I can offer even more definitive therapy.
Speaker 2 (17:25):
So if they're already coming and have been on the medicine,
do you still have to continue with the medicine or
they oh, okay.
Speaker 1 (17:31):
So that's the good thing. So I always looked when
the first question asked is have you tried gabatpentin, have
you tried lyrica? And if they said yes, I tried them,
I failed them, I'm like, oh, you great, You've at
least met that checkbox. Now, the thing is, the reason
why these drugs came down in the first place is
that they were designed in the wake of the opiate crisis.
We had a lot of patients who were on opioids,
(17:52):
and they found that if you took gabapentin unfortuately have
taken at very high levels, like five times or more
of the recommended dose, you get a similar feeling of
the opioids, but without some of the problems that you
have with opioids. Unfortunately, that's one of the problems is
that you know a lot of patients are now I
don't want to say they're not hooked on gallpenon, although
(18:14):
there's a way to get them off it, but there's
a withdrawal that patients have once you're on gabapentent and
when to get you off it. But the vast majority
of patients I've found is less than fifty percent of
patients respond to gallpenton, which is kind of weird, because
why are we offering these drugs if it's less than
fifty percent? Release your front line exactly. Unfortunately, you know,
(18:35):
if I offered a treatment I said only fifty percent
of my patients who are getting a surgical procedure or
getting improvement, we wouldn't be offering it very often. But
when it comes to these drugs, we have to offer
it as a first line because it's a cheaper way
to at least do some of the initial work. Because
gallpenton is pretty much automatically approved by ninety percent of
(18:57):
insurers because.
Speaker 2 (18:57):
To remove that rule for people that have already repressed
exactly story system exactly.
Speaker 1 (19:03):
So I mean we're not just seeing those I've seen
different changes in behavioral out to some patients. We'll get
into easily angered, easily depressed on these on these medications
like gabapentin, a lot of side effects that I'm seeing,
So really my goal is to get you off in general,
with my streament is get you off gallapenton, get you
off chronic opioid use in general with my treatment, So
(19:24):
I'm going to kind of go in a different direction here.
On the final segment.
Speaker 3 (19:30):
You're listening to the Medical Hackers with doctor Sandy Row
Board certified vascular interventionalist, bringing you insights on treatments for
common medical problems on news radio six ninety KTSM. For
more information on the issues being discussed, or to contact
doctor Rao, call nine one five five hundred four to
three seven zero or by emailing Rao at medical hackers
(19:53):
dot com.
Speaker 1 (19:57):
Now, remember I normally treat patients with knee pain, shoulder pain,
but a recent of patient came in with ankle arthritis. Okay,
it was actually a young guy.
Speaker 2 (20:05):
Didn't even know that was a thing.
Speaker 1 (20:07):
No, it is absolutely the ankle joint, you know, it's
any joint can get arthritis. Obviously, the most common ones
that we see are the more those joints that bear
the brunt of most of your activity. That's why I
see mostly patients of knee pain basis on ne arthritis,
patients who are trying to avoid knee replacements, and so
(20:29):
they come to see me for these minimally invasive treatments,
and the shoulders also somewhat seen because patients sometimes just
over the course of their life, they may have had
maybe just overwork shoulder injuries things like that. I get
a lot of mechanics who are kind of under cars
and they're having to, you know, lift their hands up
a lot, and they've just developed a lot of shoulder
(20:50):
arthroatis things like that, and they're again trying to avoid
a big surgery, and so they come to see me.
I do a minimally invasive procedure where I put medication
directly into the shoulder joint or knee joint through the
blood vessels to decrease the inflammation in those joints. Okay,
that was one step of it. Now the other part
(21:12):
of it is if patients said, if they don't qualify
for that treatment because of their insurance, sometimes I can
offer them a way to go after the nerves that
are in that region. I can put a little device,
a tiny little wire to basically distract them from the
pain signals that are normally being generated in that joint
and I'm putting in a different signal. So those are
(21:33):
sort of the ways that I attack arthritis. Now, I
recently had a patient who came in with ankle arthritis.
Really didn't know what was causing it, why he had
come in, But on MRI we found he had sort
of the classic hallmarks that you see with arthritic change
in a joint. You saw a lot of fluid build
up in the bones in the ankle. But this patient
(21:55):
isn't really a candidate for any of the really major
surgeries out there. So when people think about ankle arthritis,
it's really fundamentally different from hip or knee arthritis because
when you think about ankle arthritis, it's classically post traumatic
in nature, meaning you've had some sort of a injury,
maybe you had a trauma, a fracture, And they're now
(22:18):
finding increasingly they're finding that it could also be just
multiple stages of instability in your ankle could also be
causing that. Now, I'm actually somebody who's in the past,
I've had a lot of ankle instability. I've had ankle
sprains sometimes, I've frequently sprain my ankle, not frequently, but
maybe once a year or so. I might sprain my
(22:39):
ankle if I'm running the wrong way. That's why I
actually kind of cut down a lot of running from
my exercise regimen. But by having frequent ankle sprains, simple
ankle sprains can over time lead to debilitating ankle arthritis.
So they're finding ankle instability could be something that could
be causing some people have what we call rheumatoid disease,
(23:00):
that could be an inflammatory change within the ankle joint.
But most treatments for ankle arthritis is what we call conservative,
meaning we just treat you with medication. We try not
to do any big procedures. We try not to even
offer my procedures. It's really bracing of that ankle joint,
(23:22):
having weighing ankle, you know, an ankle sleeve, an ankle
protect or something that will really serve to limit that motion.
Injections can be used. You could do some steroid injections
if needed. Physical therapy nonsteroidal anti inflammatory medications are sort
of the key thing with ankle arthritis. But what happens
(23:42):
when you get to what we call endstage ankle arthritis
and that point that's where people need to start thinking
about some of these surgeries. So we see this every
now and then I see it on X ray. I
know there's obviously surgeons who offer this, but some patients
can get There's one or two options when it comes
to a surgical approach to ankle arthritis if you have
this end stage ankle arthritis disease. One is they just
(24:05):
fuse your entire ankle. What they do is they basically
instead of saying, you have a joint that's in motion
that's causing this pain. Because remember, whenever you have a joint,
what tends to cause that pain is the motion at
that joint. So what they do is now they will
now just freeze that joint. The way they freeze it
(24:26):
is you put a lot of hardware in there and
you fuse the joints. So at this point, now your
ankle is not gonna have much motion, thereby limiting the
motion limiting the pain that can come from it. That's
one option. Unfortunately, that's gonna probably lead you to a
different abnormal gait you're walking is gonna be different pain
(24:46):
another joint exactly. So that's one of the side effects
of having a ankle joint fusion. So some folks are
also offering ankle replacements. So ankle replacements are something that's
actually it's actually old technology is actually proved back by
the FDA and the nineteen nineties. Okay, so they have
the same way you might have a knee joint replacement
(25:07):
and shoulders joint replacement, there are ankle joint replacements. So
what you see is it's very similar sort of things today.
What they'll do is they will take out a portion
of that of that bone, the of the the tailists,
the calcanes that we see there that's at your ankle,
and they replace it with a metal. They cement that
(25:27):
in and that's something that we see. So there's been
a little bit of debate about the advantages. Are there
advantage to ankle replacement versus a ankle fusion. So the
ankle replacement, the theoretical advantage is that by maintaining your motion,
what they're able to do is they can host also
(25:50):
you know, well, the benefit is that they're now maintaining
your motion, right, so now you can actually you can
actually walk without a limp, Whereas when you have a
ankle fusion, you now are going to have a limp,
You're gonna have an abnormal gait, you're gonna now you're
gonna start walking in a different way. So what you
just told me earlier. What did you say? You said, Now,
(26:12):
what's gonna happen to your other joints if you start
walking weirdly with one joint because there's some issue there.
I frequently see patients, especially in the knee joint space.
I see patients who have developed knee arth broadus on
one side and now all of a sudden, they're now
favoring the other knee, and so that's where I got
to come in and I gotta treat it. So essentially
(26:33):
the issue here is that the bottom line point is
that you know, there's different ways to treat the ankle
joint and sometimes what we found and I think we're
running on the break here, So I actually wanted to
go into a really in depth discussion on ankle joints here.
But what they found is that you might need another
major surgery ten to fifteen years down the road if
(26:54):
you've had this ankle fusion, because now you might have
problems with the other joint. There's a whole study that
I found which actually looked at comparing ankle fusion studies
versus ankle ankle joint replacement, and so they actually found
some interesting studies. But I'm gonna have to use that
as a teaser for a future episode. But really the
(27:15):
point in the bottom line point is that we have
found revision rates at ten years following about ten percent
following even ankle joint replacement study. So if you have
an ankle joint replacement versus a fusion, there's still a
revision rate, meaning they still have to go back in
and they may have to go back into your ankle
the surgeon will after about ten years. So really the
(27:38):
point is that I try to offer patients minimally invasive
treatments to sort of kick that can down the road
of needing a big surgery. That's where my treatments come in.
Where we come in and I put in this medication
and I've done this now also for the ankle joint.
It's a little bit more tougher with the ankle joint
when you go into these blood vessels because there's so
many vessels that feed the ankle joint from the ant
(28:00):
sus your tibul artery for the poster tibularity, the parony artery.
So I did a procedure here where I offered a
young gentleman a way to avoid that and push that
down the road. And he's doing well. Unfortunate our time,
this Saturday's up. If you are interested in many more
information on some of these mentioned minimally invasive treatments, you
can always call to get more information at nine one
(28:20):
five five hundred forty three seventy that's five zero zero
four through seven zero. You're also reaching by email at
raw at medical hackers dot com. It's r Ao, that's
my last name, raw at medicalhackers dot com. I hope
these healthcare hacks have helped you navigate a complex medical system.
If you've been tuned into us this whole time, bless
your heart and your health. I'm doshor Sandy Brown. You've
(28:42):
been listening to the medical hackers.
Good afternoons of the weekend year the heart of the
dusty Choo desert in the West Texas, and you're just
maintain two the medical hackers. However, he may be tuned
in this week, and I'm your host, doctor Sandy Browt.
I'm here to bring the borderland the lace information in healthcare,
medicine and technology on this show. I consider myself a hacker,
(00:25):
a hacker apologicians, a hacker using mind intimate knowledge of
the medical system, health of breaking down from the bear's
accessing new medical technologies and current healthcare information. So it's
just myself in the studio today and Namber's producing us
always exactly. Now. I don't know if you remember this,
z Amber, but on a prior show, I discussed patients
(00:49):
who came in with shoulder pain and how I approached
them from two different standpoints. On that show, I think
we had Juni as a He was also on the show,
so I remember discussing this with him, and I wanted
to do a follow up because I've gotten a question
about why did I offer different treatments for patients who
(01:12):
have very similar symptoms. So both these patients have or
had at this point, they had shoulder pain, and I
decided to offer them two different treatments. One was a
point of attack was going after the nerves that's supplying
the shoulder that gives rise to a lot of the
(01:37):
sensation that you get in the shoulder and the upper arm.
The other patient, I attacked that problem from the standpoint
of going after the blood vessels that supplying the shoulder joint.
Now the PostScript to this thing is that both patients
actually got good results. They were able to get improvement
(01:59):
in their pain. Mostly they're having a lot of pain
at night when they were sleeping, they had shoulder pain,
that pain whenever they try to initiate movement. But both
these patients got good results. But the question that is
often asked of me is how do I decide what
treatment to offer a patient. So there's a lot of
(02:22):
different things that go into it. Sometimes it's based on
MRI findings I might see. Sometimes they might be based
on an X ray finding. Sometimes it's based on if
they have a definite known diagnosis of what we call
frozen shoulder's called adhesive capsulitis. That's a sort of an
inflammatory process that's been involving the shoulder capsule that might
(02:43):
point me in a different direction as opposed to another
patient who just had no significant loss in range of
motion but just had an ongoing shoulder pain. So there's
definitely a significant component to it that involves the patient's
clinical presentation. But unfortunately, another thing that plays a significant
(03:07):
role in how I decide to treat a patient, unfortunately
is the patient's insurance. And I want to kind of
get into that because there's actually some changes happening with
one of the insurances that I actually gives me the
most freedom to treat patients. Okay, So the freedom that
the insurance that gives me the most freedom in the
(03:28):
most leeway, and I can say, you know what, with
you came in, I can offer you pretty much anything
that's available to us. Is actually Medicare. Okay. That's that's
the government insurance as a federal government program that covers
patients who are sixty five and older, and the benefit
of having Medicare when a patient comes into me, which
(03:49):
is just straight Medicare, I'm not talking about any of
these what we call Medicare replacement plans. So a lot
of these insurers take like your private insurance, like a
signal or human or United They all have gotten into
this business of called Medicare replacement plants. So what that
means is you may be eligible for Medicare based on
(04:12):
your age, based on those circumstances, but they essentially act
as a buffer, and unfortunately that actually prevents me from
offering the full range of services because they will then
you know, be able to we have to now go
through something called prior authorization. Meaning imagine you came in
(04:33):
Amber and you said, hey, I have an issue involving
my knees. Okay, I just have knee pain. I ideally
would say, you know what. I see their symptoms, I
see what you're experiencing. I'll say I think treatment A
is the best treatment, and if that fails, I'll go
with treatment B or C. Now I can usually do
that when I don't have much of a restriction from
(04:55):
a prior authorization standpoint, when I don't have to run
my medical decision making past some insure and I can
offer that I can do that now Medicare has provided
me that luxury. If you're a patient on Medicare. Now,
if you're a patient who has some of these private
insurance plans, they tend to offer hurdles where I have
(05:15):
to now go through their prior authorization, meaning I have
to now ask them can we offer treatment A, or
they'll just say, you know what, they'll they already have
a policy saying we don't cover treatment A, you can
only provide treatment B.
Speaker 2 (05:31):
That seems like it would be very frustrating because I've
known you long enough to know that you really care
about your patient's health and like for you to have
to go through those channels, you know when you know
what would work best. It just sounds frustrating on the doctor's.
Speaker 1 (05:45):
Oh for sure. So this is something that actually affects
a lot of doctors. So now you might remember back
in I suppose is maybe last December when we had
the entire the the United Healthcare CEO got gun down. Yes, yes,
so that actually brought about a decent amount of changes
(06:05):
because that the entire reason why the he did it,
Luigim Mangoni. You know, his ostensible purpose was that he
was didn't like this entire culture of deny, delay and deny,
which is what a lot of insurance companies do, which
is what they try to do is they will you know,
(06:26):
just automatically deny requests or what's happening increasingly is a
lot of these insurance companies are using AI, artificial intelligence
to automatically deny deny like keywords or exactly. And so
so what they did a study here pro public that
did and they looked at a two month period of
time at doctors who were reviewing these claims at SIGNA.
(06:49):
So the amount of time they spent on average for
SIGNA per case, the amount of time on average they
spent was one point two seconds because they had already
we had this dashboard of the AI had told them
this is not going to meet the criteria. That's not
gonna meet the criteria, so they can just immediately deny
a lot of these these claims. And so usually they
(07:14):
found that, you know, these AI tools increase prior authorization denials,
and you know, obviously by getting more denials that sort
of now we have to as physicians, as clinics, we
have to appeal them. And so there's a long process
that involves appealing these these cases. So and there's this
(07:35):
Law journal article that came out which looks at these
appeals and the algorithm that goes through it. And what
they've found is that sometimes these AI algorithms. What they
do is they look at patient's life expectancy. So what
they'll say is if a patient is expected to die
within a certain period of time. They really rely on
these algorithms because what they have found is that as
(07:57):
time passes, we have to now force to submit an appeal,
and that actually, unfortunately increases the chance that the patient
will die during that period of time, which point they
may never have to pay that claim. So these are
all things that we have issues with. Now here's where
it is going to become more frustrating for me, because
(08:18):
this news just came out. Medicare, which was the insurance
of choice for a lot of US docs, is now
starting in January one of this upcome here January one,
twenty twenty six, running all the way through twenty thirty one.
They're doing a pilot program which they are now going
to launch a AI algorithm, an artificial intelligence algorithm to
(08:44):
look at a lot of these services. And so two
of the services are actually that we are listed are
services that I offer. So part of what I do
is I said to nerve stimulation, So they're looking at
electrical nerve stimulation, which is one of the treatments that
I had to offer this patient. Yeah, what a lot
of success for pain, shoulder pain, back pain. But that's
(09:04):
a federal expansion into this entire area of prior authorization.
So unfortunately, now something that we never had to think about,
which was having to get prior authorization, now we're gonna
have to go through prior authorization. And just you know,
this entire prior authorization program does not cover the entire country.
It only covers these following states Arizona, Ohio, Oklahoma, New Jersey, Washington,
(09:28):
and Texas. So now it's definite gonna affect me because
I do have practice that covers Texas and Arizona. So
this is gonna be something that I'm going to be
seeing and looking at very very closely because I'm now
concerned that some of a lot of these patients that
I would have gotten authorization for these treatments, I'm not
(09:49):
going to be able to treat them, or at least
now it's going to be posing additional hurdles which could
possibly cause unfortunately irreparable harm and maybe even and death.
You know that that's that's certainly they the thing that
we're trying to avoid here. So just something to know
this whole program, if you want to read more about
it's called the pilot program is called WISER. That's what
(10:13):
they've they've labeled it. WISER stands for Wasteful and Inappropriate
Service Reduction, so w I s e ER. That's the
name of this AI algorithm that they are now going
to implement for some medicare services, and they're also going
to apply it to ne arthroscopy. So a lot of
(10:34):
patients have knee pain, patients who have need skin substitutions
for wound carry on another area that I cover. So unfortunately,
there's going to be a lot of coverage of this
unfortunate plan into my clinical space. So I'm sure I'll
have more information for you going in the future, but
we'll take a quick break here in the Hackers and
go in a little bit different direction.
Speaker 3 (10:54):
You're listening to the Medical Hackers with doctor Sandy brow Board,
certified vascular Intervtwist bringing you insights on treatments for common
medical problems on news Radio six ninety KTSM. For more
information on the issues being discussed, or to contact doctor
Raw call nine one five five hundred four three seven
zero or by emailing Raw at Medical hackers dot Com.
Speaker 1 (11:21):
All right, back here on the Hackers doctor rau here,
I want to talk about a drug that's rapidly growing. Amber.
So the fifth most prescribed drug in the US in
twenty twenty four was a newer drug. It's not a
newer drug, unfortunately, that's actually a drug that's been out
for a while while, but it's actually significantly jumped into
(11:41):
doctor's arsenal. And that's a drug called gabapentin. I see
a lot of patients for on it. And it's a
generic drug, so it's not some drug that is very costly,
but it's a drug that's actually it's now jumped from
being in about twenty ten, about fourteen to fifteen years ago,
(12:03):
about six million people in the US took gallop pen,
but now that's jumped all the way to sixteen million people.
So it's a very very common drug now. And especially
if you're like me and you're a doc or a
practitioner in the space where you treat a lot of
patients who are chronic illnesses, chronic pain, this is a
(12:23):
drug that is very very frequently seen.
Speaker 2 (12:27):
Is it a pain killer?
Speaker 1 (12:28):
So it is a drug that is actually approved specifically
for seizures. It's an anti seizure drug and it's designed
to go after something also called post herpetic neuralgia. Those
are the official indications, So that means patients who've had
herpes related illnesses, who've developed neuralgia, meaning nerve related pain.
(12:50):
It's a pain. It's a drug that goes after nerve
related pain. Now there's also an approval for patients who
have restless leg syndrome, so patients are typically they have
just constant need to move their legs for whatever reason.
I see a lot of those patients as well. And
these drugs, even though there are very limited indications, which
(13:11):
I said just those three indications of the main things
that people are officially treated for, they have now become
widely prescribed for a wide variety of diseases in the
pain space. For patients who have neuropathy, which is what
I see a lot of patients who have a lot
of numbness and tingling in their feet and their hands,
(13:33):
often relate to diabet betic complications. Patients who have chronic
low back pain. It's frequently prescribed for these patients. But
the reason why this comes to me is a lot
of patients want to get off this drug. Okay, a
lot of folks don't like this drug. There's a lot
of common side effects with it. Patients who have drowsiness, dizziness,
(13:57):
blurry vision, double visionicult to coordination, concentration, And in twenty nineteen,
the FDA actually came out with the warning saying that
there are serious breathing problems with patients who take gabapentin
or the other drug in this space pregabble in Lyrica
(14:18):
with patients of underlying respiratory illnesses. So, if you have
an underlying asthma or COPD or emphysema and you're taking gabapentin,
these drugs can actually depress your central nervous system, meaning
your ability to breathe. So, especially if you're an older individual,
which is what a lot of these patients are on,
we're seeing a lot of side effects and so a
(14:41):
lot of patients come to see me because they want
to get off this drug. And that's where a lot
of my treatments come into place. So a lot of
my treatments, especially for patients who have low back pain
or patients who have neuropathy in their feet, I do
procedures involving nerve stimulation minimally invasive procedures where I go
(15:01):
in and put tiny little leads electric wires either near
their knee joint or near their back. And what I'm
just what I'm trying to do is I'm trying to
stimulate the nerves in the back or in the in
the lower extremity, and I'm trying to have different signals
(15:21):
replace your pain signals that are traveling on those nerves.
Speaker 2 (15:27):
And I would think that that way would be more
targeted than just taking a medicine exactly.
Speaker 1 (15:32):
Now you might be wondering what do I do with
this drug? Do I prescribe it? In fact, what you
might be curious to know is this is actually a drug.
Despite all these problems that we have with these with
this drug, despite all the complaints, It's actually a drug
that I prescribe and have to prescribe it unfortunately quite frequently.
(15:53):
Now you may be wondering, why do I need to
do that? Why is this drug at all these negative
things about? Why do I have to prescribe it? Now?
Unfortunately a lot of insurers require that patients have tried
these medications and failed these medications before we can offer
(16:14):
them the definitive therapy. So that's the reason why I
have to do it.
Speaker 2 (16:17):
How long do they have to be on it before
insurance is like all right, try something else.
Speaker 1 (16:20):
Yes, So I have tried a variety of different things.
So the official recommendations from some insurers is you need
to try it for least three to six months. Okay, Now,
some interurs I've seen, you know, they might I can
put them on for a month and then once the
patient has the side effects and then maybe I can
get them off it. But usually they want me to
(16:41):
try it for a certain period of time. Now, most
patients who come to see me, they've already been put
on this drug by their primary docs. So actually primary
care docs and nurse practitioners are actually the single most
common prescribers of this medication. So that's because it's hugely
considered a front line medication sort of like a It's
(17:02):
something that the gatekeepers who see these patients should ideally
put the patient on and so hopefully that once they failed,
then they come to see me. But unfortunately, I have
to try these medications first, have you fail unfortunately experienced
these bad side effects, and then at that point then
(17:24):
I can offer even more definitive therapy.
Speaker 2 (17:25):
So if they're already coming and have been on the medicine,
do you still have to continue with the medicine or
they oh, okay.
Speaker 1 (17:31):
So that's the good thing. So I always looked when
the first question asked is have you tried gabatpentin, have
you tried lyrica? And if they said yes, I tried them,
I failed them, I'm like, oh, you great, You've at
least met that checkbox. Now, the thing is, the reason
why these drugs came down in the first place is
that they were designed in the wake of the opiate crisis.
We had a lot of patients who were on opioids,
(17:52):
and they found that if you took gabapentin unfortuately have
taken at very high levels, like five times or more
of the recommended dose, you get a similar feeling of
the opioids, but without some of the problems that you
have with opioids. Unfortunately, that's one of the problems is
that you know a lot of patients are now I
don't want to say they're not hooked on gallpenon, although
(18:14):
there's a way to get them off it, but there's
a withdrawal that patients have once you're on gabapentent and
when to get you off it. But the vast majority
of patients I've found is less than fifty percent of
patients respond to gallpenton, which is kind of weird, because
why are we offering these drugs if it's less than
fifty percent? Release your front line exactly. Unfortunately, you know,
(18:35):
if I offered a treatment I said only fifty percent
of my patients who are getting a surgical procedure or
getting improvement, we wouldn't be offering it very often. But
when it comes to these drugs, we have to offer
it as a first line because it's a cheaper way
to at least do some of the initial work. Because
gallpenton is pretty much automatically approved by ninety percent of
(18:57):
insurers because.
Speaker 2 (18:57):
To remove that rule for people that have already repressed
exactly story system exactly.
Speaker 1 (19:03):
So I mean we're not just seeing those I've seen
different changes in behavioral out to some patients. We'll get
into easily angered, easily depressed on these on these medications
like gabapentin, a lot of side effects that I'm seeing,
So really my goal is to get you off in general,
with my streament is get you off gallapenton, get you
off chronic opioid use in general with my treatment, So
(19:24):
I'm going to kind of go in a different direction here.
On the final segment.
Speaker 3 (19:30):
You're listening to the Medical Hackers with doctor Sandy Row
Board certified vascular interventionalist, bringing you insights on treatments for
common medical problems on news radio six ninety KTSM. For
more information on the issues being discussed, or to contact
doctor Rao, call nine one five five hundred four to
three seven zero or by emailing Rao at medical hackers
(19:53):
dot com.
Speaker 1 (19:57):
Now, remember I normally treat patients with knee pain, shoulder pain,
but a recent of patient came in with ankle arthritis. Okay,
it was actually a young guy.
Speaker 2 (20:05):
Didn't even know that was a thing.
Speaker 1 (20:07):
No, it is absolutely the ankle joint, you know, it's
any joint can get arthritis. Obviously, the most common ones
that we see are the more those joints that bear
the brunt of most of your activity. That's why I
see mostly patients of knee pain basis on ne arthritis,
patients who are trying to avoid knee replacements, and so
(20:29):
they come to see me for these minimally invasive treatments,
and the shoulders also somewhat seen because patients sometimes just
over the course of their life, they may have had
maybe just overwork shoulder injuries things like that. I get
a lot of mechanics who are kind of under cars
and they're having to, you know, lift their hands up
a lot, and they've just developed a lot of shoulder
(20:50):
arthroatis things like that, and they're again trying to avoid
a big surgery, and so they come to see me.
I do a minimally invasive procedure where I put medication
directly into the shoulder joint or knee joint through the
blood vessels to decrease the inflammation in those joints. Okay,
that was one step of it. Now the other part
(21:12):
of it is if patients said, if they don't qualify
for that treatment because of their insurance, sometimes I can
offer them a way to go after the nerves that
are in that region. I can put a little device,
a tiny little wire to basically distract them from the
pain signals that are normally being generated in that joint
and I'm putting in a different signal. So those are
(21:33):
sort of the ways that I attack arthritis. Now, I
recently had a patient who came in with ankle arthritis.
Really didn't know what was causing it, why he had
come in, But on MRI we found he had sort
of the classic hallmarks that you see with arthritic change
in a joint. You saw a lot of fluid build
up in the bones in the ankle. But this patient
(21:55):
isn't really a candidate for any of the really major
surgeries out there. So when people think about ankle arthritis,
it's really fundamentally different from hip or knee arthritis because
when you think about ankle arthritis, it's classically post traumatic
in nature, meaning you've had some sort of a injury,
maybe you had a trauma, a fracture, And they're now
(22:18):
finding increasingly they're finding that it could also be just
multiple stages of instability in your ankle could also be
causing that. Now, I'm actually somebody who's in the past,
I've had a lot of ankle instability. I've had ankle
sprains sometimes, I've frequently sprain my ankle, not frequently, but
maybe once a year or so. I might sprain my
(22:39):
ankle if I'm running the wrong way. That's why I
actually kind of cut down a lot of running from
my exercise regimen. But by having frequent ankle sprains, simple
ankle sprains can over time lead to debilitating ankle arthritis.
So they're finding ankle instability could be something that could
be causing some people have what we call rheumatoid disease,
(23:00):
that could be an inflammatory change within the ankle joint.
But most treatments for ankle arthritis is what we call conservative,
meaning we just treat you with medication. We try not
to do any big procedures. We try not to even
offer my procedures. It's really bracing of that ankle joint,
(23:22):
having weighing ankle, you know, an ankle sleeve, an ankle
protect or something that will really serve to limit that motion.
Injections can be used. You could do some steroid injections
if needed. Physical therapy nonsteroidal anti inflammatory medications are sort
of the key thing with ankle arthritis. But what happens
(23:42):
when you get to what we call endstage ankle arthritis
and that point that's where people need to start thinking
about some of these surgeries. So we see this every
now and then I see it on X ray. I
know there's obviously surgeons who offer this, but some patients
can get There's one or two options when it comes
to a surgical approach to ankle arthritis if you have
this end stage ankle arthritis disease. One is they just
(24:05):
fuse your entire ankle. What they do is they basically
instead of saying, you have a joint that's in motion
that's causing this pain. Because remember, whenever you have a joint,
what tends to cause that pain is the motion at
that joint. So what they do is now they will
now just freeze that joint. The way they freeze it
(24:26):
is you put a lot of hardware in there and
you fuse the joints. So at this point, now your
ankle is not gonna have much motion, thereby limiting the
motion limiting the pain that can come from it. That's
one option. Unfortunately, that's gonna probably lead you to a
different abnormal gait you're walking is gonna be different pain
(24:46):
another joint exactly. So that's one of the side effects
of having a ankle joint fusion. So some folks are
also offering ankle replacements. So ankle replacements are something that's
actually it's actually old technology is actually proved back by
the FDA and the nineteen nineties. Okay, so they have
the same way you might have a knee joint replacement
(25:07):
and shoulders joint replacement, there are ankle joint replacements. So
what you see is it's very similar sort of things today.
What they'll do is they will take out a portion
of that of that bone, the of the the tailists,
the calcanes that we see there that's at your ankle,
and they replace it with a metal. They cement that
(25:27):
in and that's something that we see. So there's been
a little bit of debate about the advantages. Are there
advantage to ankle replacement versus a ankle fusion. So the
ankle replacement, the theoretical advantage is that by maintaining your motion,
what they're able to do is they can host also
(25:50):
you know, well, the benefit is that they're now maintaining
your motion, right, so now you can actually you can
actually walk without a limp, Whereas when you have a
ankle fusion, you now are going to have a limp,
You're gonna have an abnormal gait, you're gonna now you're
gonna start walking in a different way. So what you
just told me earlier. What did you say? You said, Now,
(26:12):
what's gonna happen to your other joints if you start
walking weirdly with one joint because there's some issue there.
I frequently see patients, especially in the knee joint space.
I see patients who have developed knee arth broadus on
one side and now all of a sudden, they're now
favoring the other knee, and so that's where I got
to come in and I gotta treat it. So essentially
(26:33):
the issue here is that the bottom line point is
that you know, there's different ways to treat the ankle
joint and sometimes what we found and I think we're
running on the break here, So I actually wanted to
go into a really in depth discussion on ankle joints here.
But what they found is that you might need another
major surgery ten to fifteen years down the road if
(26:54):
you've had this ankle fusion, because now you might have
problems with the other joint. There's a whole study that
I found which actually looked at comparing ankle fusion studies
versus ankle ankle joint replacement, and so they actually found
some interesting studies. But I'm gonna have to use that
as a teaser for a future episode. But really the
(27:15):
point in the bottom line point is that we have
found revision rates at ten years following about ten percent
following even ankle joint replacement study. So if you have
an ankle joint replacement versus a fusion, there's still a
revision rate, meaning they still have to go back in
and they may have to go back into your ankle
the surgeon will after about ten years. So really the
(27:38):
point is that I try to offer patients minimally invasive
treatments to sort of kick that can down the road
of needing a big surgery. That's where my treatments come in.
Where we come in and I put in this medication
and I've done this now also for the ankle joint.
It's a little bit more tougher with the ankle joint
when you go into these blood vessels because there's so
many vessels that feed the ankle joint from the ant
(28:00):
sus your tibul artery for the poster tibularity, the parony artery.
So I did a procedure here where I offered a
young gentleman a way to avoid that and push that
down the road. And he's doing well. Unfortunate our time,
this Saturday's up. If you are interested in many more
information on some of these mentioned minimally invasive treatments, you
can always call to get more information at nine one
(28:20):
five five hundred forty three seventy that's five zero zero
four through seven zero. You're also reaching by email at
raw at medical hackers dot com. It's r Ao, that's
my last name, raw at medicalhackers dot com. I hope
these healthcare hacks have helped you navigate a complex medical system.
If you've been tuned into us this whole time, bless
your heart and your health. I'm doshor Sandy Brown. You've
(28:42):
been listening to the medical hackers.
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