I need your help - abuses in medical practice and insurance.

[mmglobal]

2 years ago, I was asked to represent the patient community at the Third International Conference on Ethical Issues in Biomedical Engineering. (website) I have been invited to return and again, represent the patient community in a panel discussion on "Marketing, Payment and Regulation of Biomedical Devices" at the Fourth Internation Conference on Ethical Issues in Biomedical Engineering. (website)

I'll be making a presentation and then participating in the panel discussion on marketing, reimbursement and regulation. I'd like my presentation to cover:

• A balanced view of positive and negative impact of new technologies on the spine patient community.
• Case examples of abuses by the system as related to introduction of new devices. (read more below)

Abuses by the system may include, but are not limited to:

• reimbursement issues
• reimbursement issues
• informed consent
• reimbursement issues
• Workmen's comp abuse
• reimbursement issues
• Clinical trial, oversight of unsuccessful patients
• Complication reporting - outcome database - can't we weed out the bad surgeons?
• Oh yes... did I say reimbursement issues.

I spoke to Dr. Subrata Saha this morning. This year well over a dozen countries will be represented and the conference is growing nicely. I really enjoyed the conference in 2005 and look forward to this one. Late April in New York should be nice... perhaps we can have a spiney gathering there... Sunday afternoon 4/22?

[mmglobal]

I forgot to post... the help I want from the patient community is... I want to connect with patients who've suffered the worst of the worst of abuse by the system. Have you been told that you have to stop meds and go to boot camp in spite of the fact that you've got hard clinical data demonstrating severe pathology? Have you been scheduled for appointment for appointment and then have them cancelled on short notice? Have you had your funds cut off from your disability insurance company and they confess to a clerical error but it still takes 8 months to get it turned back on and meanwhile you lose your house? Did WC cash you out and you found yourself, after a WC injury, unemployable, uninsurable, unable to get SSD and basically fallen through the cracks unable to get appropriate medical care and have no options?

Did you have your doctor tell you that you were going to be is first or second time using a brand new device, but it's no big deal; only to discover that it is a very big deal and for many reasons, your life may have been ruined for lack of informed consent?

I want to talk to these people! I go to surgeon's conferences and hear presentations about research on patient abuse. This research gives the WC, legal and insurance industry political cover to deny needed treatment to people who really need it. I'd like to demonstrate that even worse than the patient abuse is the abuse by the system.

If you know these folks... send them to me. you can send email to the info address on iSpine or GPN websites.

Thanks in advance for the help.

Mark

[Poncho]

Okay, - Lets see - to get the ball rolling here --- I can relate to this as a work comp patient. However, my injury and ADR surgery was prior to FDA approval of any of the ADR's.

In my case, I felt that work comp was in a rush to place me in what they call MMI (maximum medical improvement). Pushing to have a functional capacity exam performed to determine percentage of disability. The doc was trying to trick me into going through the functional capacity exam and have me sign the documents that I would agree that this was the percentage level of permanent disablity. - They did not inform me that going through this would cut off my work comp benefits at the time. Nor did they inform me that I qualified for lifetime benefits under work comp related to my back. Most of the jobs involved lifting - I was unable to lift anything over 10 pounds. - Also, they would not give me a copy of my pateint rights - so that I would know what I was or was not entitled to. I had to do all the research on my own in pain, drugged up - etc.

I found out through forums like this prior to going through the functional capacity exam that this was a "trap" that once going though and signing those documents - I would be forced to find a permanent job within 30 days I believe within the hospital I worked for or have my "employment relationship severed" with them. Needless, I refused this functional capacity exam and any paperwork that went with it. Fought like hell and won my case with HR regarding job placement and did end up with a desk job. But, like I mentioned had to fight like hell....Another nurse that was a cervie, went through a similar process as myself - but went through the functional capacity exam. She signed the papers as they pertain to the exam and was cut a check (measly check at that) and told her case was closed because she was at MMI and the check was her "compensation"...

I have to do some more thinking here - but it is at least a start.

Poncho

[Poncho]

As far as playing the system for reimbursement. One of the ADR docs in the US I consulted with said that because there was not an insurance code or ICD-9 code for ADR that he would code it as an "intra - dynamic spacer" - in an attempt to receive reimbursement that way.

As far as clinical trial "oversights" - It seemed that here in the US, my case kept getting pushed back further and further on the waiting list. Waited on the list for 1 1/2 years before just giving up and going to Europe.

I never took my name off their list - and they never called me to set up surgery even after 2 surgical consults and discogram plus MRI's and all of the diagnostics proving the pathology AND being told that I was a candidate. I think that was 4 years ago...Hummm.... ( I won't mention names online )

Another issue as far as reimbursement....those of us that do have the financial resources to pay out of pocket (some of selling homes, cars, taking out loans, or charging up credit cards & etc to get lives back)- There needs to be more transparency as far as the price / costs associated with going through such a procedure. Granted, any complications can set one back more $$$ - but if the surgical clinics in Europe can give some sort of ball park estimate - why can't we???

Still trying to brainstorm some thoughts here.

[sahuaro]

One of the many good points Poncho raises is that of "Independent" Medical Examiners--doctors who prostitute themselves and abuse their medical licenses as "consultants" for insurance companies and WC. And they are immune from review from the state Medical Board because "there is no patient/doctor relationship." I don't know if this falls in the purview of your presentation, Mark, but I sure can provide some first-hand information--just let me know.

[Poncho]

Excellent point Sahuaro,

I wonder if this is regulated by the states? I'm thinking work comp laws vary from state to state.

[Ron]

Well I was only supposed to be in the hospital for 3 days after surgery, but they kept me there for 6 cause of their ineptitude not because I needed to be there. Not to mention all the BS charges on the bill that eventually racked up $140,000 in claims, yet no itemization has arrived in my mail or at the insurance company. Additionally they didn't tell me some doctors participating in the surgery were out of network.

Send me a PM if you're interested in specifics.

http://img201.imageshack.us/img201/2...rybill1or0.jpg

[Maria]

I've got to wonder from that period of Oct 2005 until the recent authorization for surgery I just received, the costs alone of sending the requests for authorization for surgery thru Utilization Review and getting the numbers of non certs (denials) that I did over that 2 year period of time.

It wasn't like any of the surgeons were saying anything different re treatment or that any of the diagnostics could be misinterpreted, or that my history had changed over the last 20 years even.

I think with the Reform striving for cost containment it would be better not to linger so long over cases that are pretty much slam dunk in terms of what is proposed as treatment as that alone must be costly in terms of UR and reviews to deny for many times only to approve at later (in my case 2 years later) date.

And it's abuse to have someone have to wait that long and go thru all the WC roller coaster and then sit there and say that their goal is to return people to useful/gainful employment. If that's so, why drag out the obvious cases so long (others not just my own).

Some people are not as tenacious as myself or have the means to be so~ I was just fortunate in this manner.

[JANENE]

Well Mark,

I had my sx in November 2004, after a work-related injury, at that point I was doing well returned back to work in April 2005. In July 2005, while at work I had what the WC calls a "recurrance" I was lifting a pile of charts and BAM!!! Down to the floor I went in pain.

WC re-opened my claim, I had PT, ESI shots (the last one causing a 1-week stay in hospital, 2 blood patches, because a Resident by mistake caused a CSF leak.) etc...etc... then finally WC decided that they were going to send me for pain management in a 4-week in-stay program, away from my husband and children. If I didn not participate in this program then they would stop my payments and I would have to return back to work right away. I gave it the benefit of the doubt and went to the Orientation & Assessment for the PMP.

In April of last year my husband left me and my kids, explaining that this was all too much for him to handle and that he can't take seeing me so miserable and depressed and upset all the time. It was then that I called my Adujicator to explain to him my present situation and ask him if there was anyway that they could offer me transportation to and from the PMP daily, as I am not able to drive 50 mins there and back everyday for 4-weeks, but will not be able to stay over because I have no definate care for my 4 small children.

I never heard anything back from him. Then 2-weeks before the date of my start, I called him again and left a message as to what was going on, and he called me back explaining that because I am not participating in the programs that WSIB has offered, I am no longer going to be receiving LOE benefits. I have been cut off since June 2006.

I had my NEL (Non-Economic Loss) assessment. And was awarded a certain percentage of disability..etc..etc..etc..

So they sent me as well as my doctor outlining WHY I was being cut off of my benefits, and told that I should be back at work, there is NO reason for me to be off of work.

So, when I went to my doctor (GP) who might I add has NOT given me the okay to return to work, he told me to find a lawyer and aloow them to appeal the decision. Okay, so I did that.

It has still been 8 mths, NO MONEY, I had to go on to Social Assistance, to help me pay my bills, disability told me I had to sell my car if I wanted to get disability benefits. Which I explained to them as well as my lawyer. So the years before my WORK-RELATED accident that I worked my butt off paying for my bills, providing for my family and for myself, etc..etc.. I am just suppose to throw all those years of hard work away???

I am still fighting with WSIB (Cananda), now Social Assistance has told me that because of the amount of "support" I should be getting from my ex-husband, they can no longer give me the financial help I require, because my "gross" amount is over what thier "quota" or whatever is.. Too bad my ex isn't able to pay me what he needs to because he has to live too.

So it is getting from BAD to WORSE.......and I still have my GP telling me there is NO WAY I am able to return to work......So where do I go now?

I hope this wasn't too long.........

Janene

[dshobbies]

Wow Mark, I just wrote a thoughtful and elequant response to your request but hit a wrong button and it vanished, forever!!!!!

Abuses to our system include J&J’s greed in charging the U.S. outrageous prices for the Charite, causing in part, the ins industry’s denial of adr coverage. Doctors, ill equipped due to personal inexperience, performing procedures which result in negative outcomes necessitating supplementary medical care further skews sightable statistics. Though one is needed for the patient community, would an outcome database demonstrating ‘bad surgeons’ result in their personal patient profiles being completely discounted by risk management statisticians?

Doctors are not required to inform their patients about alternative procedures that have not yet been approved by the FDA regardless of their position in current trials and any possible benefit to their patient. Some doctors will purposely misinform patients about procedures they personally don’t perform. Does this apply to informed consent? Is it even provable? Is this matter of he said/she said even enforceable?

Though all of the above is applicable not only to the spinal community but to our entire medical society, it is nonetheless pertinent to abuses, causation against reimbursement and negatively impacts new technology, all of which are relevant to marketing, reimbursement and regulation.

Since I hail from Brooklyn, keep me informed about a spiney gathering.

Dale

[annapurna]

For those of us with regional HMO's, insurance reimbursement of ADR and other motion-preserving spine procedures are limited not only by general insurance company policies, but also by local availability of skilled surgeons.

If I want insurance reimbursement for any medical procedure, I can only go to providers in my local area, which includes northern Utah. So, if there are no ADR surgeons in the greater Salt Lake City area, I'm paying in cash regardless of what the FDA or any other policy-makers say.

As employers get pushed harder and harder by increasing medical insurance costs, they tend to shift from "open" plans like PPO's to HMO's, which are regionally-restrictive. I'm lucky in that I have a high enough income that I can pay cash when necessary, but I've still needed to sacrifice to get my L5/S1 Charite and c5/c6 Prodisc. My husband and I rent an economical apartment and own one, aged Toyota between the two of us. We have no children. All the money that our friends spend on vacations, toys, homes, cars, and kids gets poured into my spine.

It's a bit scary to consider that the progress of medical technology may be limited in the future not because the advances are not needed, but because no one is able or willing to pay for them. I'm grateful that I've been blessed with the ability to make that choice for myself and wish that it was possible for everyone to do so.

[Poncho]

This is the main reason why I am getting my MBA and hopefully attempt to figure out these approval / denial process further regarding HMO's vs PPO's et al and what recourse action patients. I believe in choices and HMO's tend to restrict this. Managed care was suppose to "control" health care costs - but it really hasn't. They have only been inflationary.

[annapurna]

Bless you Poncho! With people like you getting involved in the healthcare reimbursement system, there is hope for all of us.