The $2,000 Hip Pain: Why Systemic Solutions Matter

🎙 Talking Rehab Podcast – Episode 60: "The $2,000 Hip Pain: Why Systemic Solutions Matter"

In this episode, I walk you through a real case involving a 10-year-old boy with hip pain. What started as a simple clinical concern quickly turned into a reflection on the inefficiencies of our healthcare system. I share what it’s like navigating specialty referrals, high deductibles, and trying to advocate for timely, affordable care—while practicing in a direct care model.

If you’ve ever wondered what “value-based care” looks like in the real world, or how something as basic as getting an x-ray can spiral into a $2,000 hospital visit, this episode is for you.

🕒 Timestamps for Key Moments:

• [00:00] – Why I started the podcast and what rehab means to me
• [01:00] – Busting the myth: direct care isn’t just for the wealthy
• [02:00] – The clinical case: a 10-year-old with progressive hip pain
• [03:00] – Ultrasound findings and the red flags every clinician should know
• [04:30] – Top differential diagnoses: SCFE, LCPD, and transient synovitis
• [05:30] – Calling the pediatric orthopedist: the reality of gatekeeping and systems barriers
• [07:00] – “Send them to the ER” – the most costly, inefficient route
• [10:00] – My alternative: working around the system to avoid unnecessary costs
• [11:00] – What this experience says about our healthcare priorities
• [12:00] – A call for new care models: direct orthopedic care and transparent pricing
• [13:00] – Is ultrasound underutilized in pediatric ortho triage?
• [14:00] – A message to medical students: question what you've been taught
• [15:00] – Final thoughts and a call to rethink what "value" really means in care

🎯 Whether you're a provider, a parent, or a med student, this story is a glimpse into the decisions we’re forced to make when systems get in the way of solutions.

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👉 If this story resonated with you, subscribe, leave a review, and share the episode. Let’s continue reimagining better care—together.

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Transcript

0:00

What is rehab or rehabilitation? My name is Fred, be Garris, a board certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. I. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge, dogma, and share my experiences in musculoskeletal medicine. Welcome to The Talking Rehab Podcast. I. As a direct care practice owner, I see people with insurance, some people without insurance, some people with a very high deductible, it really ranges. I think one of the common misconceptions, I'll address is that the people that I see. Are very well to do, and, they, are looking for kind of a concierge feel with their medical care, but that's not, that's just not really true. I, my, the patients that I've been seeing really come from a fairly wide and diverse background and, I wanted to share this particular story. Of, a patient I had recently and some of the issues that, that kind of popped up as a result. And so I had a young boy, probably 10 turning 11 years old. I came in with, or I was called by the mother with a history of hip pain and, hip pain in that nine to 10-year-old range, can be from a constellation of things, but this was an. not related to a particular injury, just slowly progressive hip pain. And so I brought them in. I saw that the boy was hobbling and was, in a pretty good amount of pain. And so in my practice I use predominantly ultrasound. I don't have x-rays. because for. for certain reasons I just rely particularly on ultrasound. And the hip examination was, positive for hip pain, no focal, motor, or sensory deficits. Fairly healthy kid just anytime you move the hip, it hurt very difficult for them to get around. and so under ultrasound, I can see certain tissues. I didn't see any evidence of a bursitis, no obvious muscle tear, but I could see a small effusion of the hip joint and that is a little bit of a clue that something is actually going on. I was able to compare the right hip to the symptomatic left hip and could see that there was clearly a difference in the amount of fluid inside of the hip joint. I get a little bit of a peak of the anatomy. I didn't see anything obvious, in terms of the shape of the hip, but essentially with the, a traumatic hip picture, the differential from my standpoint can range from, having, a slip capital femoral epiphysis. That's the top of the list, where you have, a. Essentially almost a slight subluxation of the, bone slash growth plate interface, which can certainly cause pain, leg calf, perth's disease, and also transient synovitis. Now it's very difficult to tell. That there's a difference of the, it's very difficult to differentiate between these various conditions without advanced imaging, but the fact that the ultrasound could clearly see that there was an effusion within the hip joint should always kind of raise a flag. I guess maybe I should back up. Anytime you see a traumatic hip pain in a young child. And that should always raise a red flag because children, they tend to run and walk through pretty much anything. So if something slows them down, I almost always will pay attention to it. So the next step from there was, we need to get, better imaging, get an x-ray, potentially advanced imaging, uh, like an MRI, to see is there any evidence of bony edema. But not to. Go too far, too fast. I thought to myself, probably the best thing in this particular case is to have, this, particular, patient see a pediatric orthopedist, just to be safe, On the whole, there are certain conditions that you don't wanna miss. And having a, skiffy or slip capital femoral epiphysis is one of those conditions that you do not want to miss. in my practice, I enjoy collaboration. I like talking with other docs, to essentially not just deliver a better healthcare package, but also it just. Makes the whole process smoother. There's less holes. the care is generally better. Now it is definitely challenging because, in my I network of physicians, a large majority of them are insurance, based. So they have a very high volume clinic. there are some direct care orthopedists, but none of them are in my area. So the first thing was I called up the, pediatric orthopedist office. I spoke with the front desk staff. Of course, I had to get through the automations, but I finally got through and I told the staff there that, I identified as a physician and I said, I have someone who I think may have a, skiffy and, I would like them to be seen and. I do that intentionally because sometimes with medical offices, it is easier to get someone in if you have a direct, doc to doc or if you have a physician. calling personally to advocate for their patient to be seen. Sometimes, you can sneak someone in, if it's an urgent or emergent issue. So again, I try, I thought it would be a good idea to just say, Hey, this is a doc calling for another doc to see if they can do them a solid, get this one in. And so I was placed on hold and they said, let me see if we can get them in. And at this point I'm thinking, even if they were able to see somebody, you know, they can at least do a formal examination. They can get x-rays, within their system. Sometimes that's a challenge because if I did x-rays outside of their system, they may not be able to see the x-rays. And again, it can Slow down the process, or they may have to repeat the x-rays, in, in their clinic and that, delivers more radiation to the child. Nobody wants that. So again, I'm thinking how can I save, time, money, and be efficient at the same time? the staff comes back onto the phone and says, just send them to the emergency room. And I said, this isn't actually an emergency, but could they, even if there's a physician, assistant nurse practitioner, somebody just, I just want to connect this particular patient to your clinic, to make sure that, I. there's a specific handoff because what is the outcome of going to the emergency room? It ends up being like, a two to three hour visit, it's an x-ray all to see an orthopedist there that is ultimately going to say, this isnt an emergency, but I will follow up with you in the clinic. And so I explained my case was like, I was like, I am, I can send over my note. I do see there is an effusion. Even if there's more imaging that needs to be done, I can, I'm more than happy to help facilitate this. But, essentially is there anybody that can see them in the outpatient clinic? And aside from the efficiency aspect of things, I am trying to make this cost effective for this particular patient and their mother. they have, they do have insurance, but they have a very high deductible. so I'm trying to, be mindful of that. and not just the care part of things because you go to the emergency room, they take your blood pressure, they take your temperature, you accept a sandwich, all of that is billable. the simple x-ray is honest, should be like, maybe a hundred dollars, but you get an x-ray in the. In a hospital system, it's like a thousand dollars. I'm just throwing out random numbers. I think you guys get the point. It ends up being some crazy costs. And then you get consulted in the er. that the emergency room physician, you, they consult an orthopedist. these are, again, are just tacking on the bill. So again, I pleaded my case and essentially they said, just send'em to the er. And I could not get a better answer than that. So I said, just, I left my name, my number, and I said, is there, can you please just pass this message along? Long story short, I never got a call back. I wasn't about to send them to the er, because it's unproductive, and, but it got me thinking. I was like, Why would they send me there? Or why would they send their patients there? And my guess is that's where the orthopedist is. perhaps their clinic that day was, the OR day. and so they had no surgeons in clinic. And so they were thinking maybe if I, That if the patient was seen in the emergency room, the on-call orthopedist will be able to see them. playing devil's advocate, the, pediatric orthopedist side of things, maybe that was the best solution in that, that they could give me to get this, the patient, the care that they needed to be seen by an orthopedist was to go to the place where the orthopedist, for that particular day. Was scheduled, which is they're on call in the hospital. And even in that situation, that just seems like the worst, most expensive solution is let's send the patient to the ER to wait for a long period of time to get tests in the most expensive place. Only to be told to follow up in an outpatient clinic on a separate day in, in some shape or form. I think I might've just elected to okay, is there another day, this week that they can be seen that would've been a lot more efficient because, outside of the pain control, which I can manage. there isn't anything emergent that needs to happen as long as it's addressed in a timely manner and they're being, things like that. There wasn't anything necessarily emergent, and I explained that to the staff. I said, this is not an emergency. This is inappropriate. But this was the only answer. This was the only solution that they could give me. And, it got me thinking. I was like, what would the alternative be? In my particular case, what I ended up doing was, I ended up ordering the x-rays at the hospital system, because I don't have my own x-ray machine, so it ended up being a little bit more expensive than an ordinarily would've been. I've seen a, an x-ray, for a hundred dollars they charge two 50. it's fine. And I was able to read the x-rays myself. I was able to get the radiologist to get their report. So there was a little bit more supporting evidence that, okay, there's no obvious orthopedic deformity. There was nothing that says, Hey, this is something. that needs advanced imaging or emergent surgery, which is great. I ended up continuing to follow the patient, moving forward, monitoring their symptoms, writing them an excuse note from school, things like that. And I was completely fine. And I know that I had that ability in the very beginning, but I thought, I'm being conservative, just trying to do the best for my patient and Even in my own personal efforts, I could not get them to see a pediatric orthopedist. And that just, to me, I was just like, that's just a shame. It's just a, it's just a shame that, that the only option is the most expensive, inefficient option, and that's really what my practice and my mission is about, is there needs to be a different pathway. That folks need to go through because having insurance while it feels good, depending on your plan, it still might be the most expensive option. Again, this is the population I'm seeing is they have high deductibles now. in terms of the overall solutions, the only thing I can really think of right now, is to try and do what I used to do in the past, which is essentially educate and mentor, future medical students about different models of care. And I'm talking about direct care in particular. traditionally specialty care, especially orthopedic surgery is done in an, in a insurance based setting. But there are people out there who are now doing orthopedic surgery. At a flat rate, there is, transparent pricing such as my practice. I have transparent pricing so everybody knows what there's, what the bill is gonna be. There's no surprises. The consumer can certainly do, their due diligence. Price shop and also do research on the physicians that they'll be seeing. And so I just, unfortunately, the way that the healthcare system is right now, it's, I never say that it's broken, is designed exactly what it is to do, which is to bill and collect money. That is a hundred percent what the system has been designed to do. And so in my mission to try and find. Different and, different pathways to care, for the people in my community. and maybe I just stumbled across a particular solution, which is maybe we need to be using ultrasound a little bit more frequently in this particular type of care. you can see evidence of effusion. You can see. increased blood flow to the area, which can raise your suspicion for potential fracture. you can also kind of trace the cortex of the bone and if you see an irregularity again, that might raise your suspicion for getting advanced imaging. So, you know, who knows? But as it is currently taught, these three conditions, skiffy. LCP, like calf per disease and transient synovitis. These are, typically investigated with x-ray and advanced imaging. But what if that costs,$2,000, essentially an ER visit, where it's that expensive only to just land back into the orthopedist office the very next day. I just don't think that's necessary. I don't think that's value at the end of the day. that is not, how I perceive value. I am for the medical students listening out there, I am, trying to reach out to you guys. I would love to give talks at your, your clubs or do ground rounds, things like that. I think that cases like this need to be brought up, at the medical student level when you guys are still really very open. to new ideas, and I wanna make sure to inspire the next generation, so that you guys continue to do the right thing. look at the big picture, come up with other solutions, Not just the ways that have been taught to you by your attendings, which is usually an insurance-based answer. And that's just not the way, that I think medicine needs to go. So for you medical students out there, I hope you're listening to this, take this case into account, you know where to find me. Thanks again for listening. Take care. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.