Here I linked to an article in the times that discussed Medicare’s decision not to cover ADR surgery in patients over 60. As it turns out, this is not good news for ANYONE needing ADR, and possibly even fusion. Here’s why.

During my last check up, Theresa mentioned that the pace of their surgery schedule has really slowed as many/most insurance companies are now not paying for the type of surgery I got, that is, ADR combined with a fusion. They’ve narrowed the range of what is covered by adding the stipulation that there can be no other existing conditions, so if a patient needs ONE disc replaced and that’s it, ok. People like me who needed a fusion and a new disc would be shit out of luck. Thank goodness that I got my surgery when I did, as I can’t even think what the outcome might have been if I’d had to wait for even a few more months.

On top of that, I’ve been reading with interest the health care proposals of the three leading democratic presidential candidates (Clinton, Obama, and Edwards). They all seem to include/favor the formation of some kind of “institute” that would research the most effective treatments for the most common (read:expensive) health care issues.

From the NYTimes:

"Along these lines, the three leading Democratic candidates have quietly come up with nearly identical ideas. Deep inside their health care plans, Mrs. Clinton, Mr. Edwards and Mr. Obama have each called for the creation of a national institute to figure out which kinds of medical care actually work. This institute would sort through the scientific research on, say, spinal fusion and help people understand when it may make sense and when it’s likely to be just another big medical expense that doesn’t solve anything."

As back pain is one of the major health care costs, lumbar fusion and I suppose ADR, though the article didn’t specifically mention it, would be researched for their efficacy. Apparently there are some studies that show that fusion is, in some cases, no more successful in treating back pain than other methods. While this is true, and I'm not advocating that anyone and everyone who requests a spinal fusion should be able to get one, I am afraid that the insurance companies will seize on any study that supports a conclusion that means they don’t have to pay for a procedure. The Times article goes on to state that Medicare and the insurance companies would then use the research to “determine when a procedure or a drug would be covered” (read: they’d use the research to deny coverage).

Of course, this is all just my opinion, and wouldn't it be nice if I were proven wrong, but if there's anything I've learned in the past year or so, it's that insurance companies are pretty predictable when it comes to cutting what they cover and putting more of the insurance premiums we pay into their own pockets.

Medicare Denies ProDisc Coverage

From today's Times: This is not good news.

Incidentally ...

Here's the statement from the insurance company for my surgery. As you can see (click on the photo to see it larger), the hospital was allowed just over $71,000 for "incidentals." If you think that is bad, we saw the documentation on the insurance company's website showing that the hospital actually asked for $153,000 for the "incidentals." The fact that they're getting just under half of what they asked for sounds cheesy on the insurance company's part, and luckily, our insurance company did cover those incidentals, no problem, so we don't have to pay.

Still, I'm curious as to just what exactly those incidentals were. I mean incidentals are defined as things that are minor, casual or subordinate. Subordinate to what? Well, things that are not incidentals, but essentials.

So is this charge for things like those little bottles of Keri lotion or the infernal baby powder they are always pushing on you when you are a patient? Actually I think those things are better categorized under "sundries," but there wasn't a category on the statement for that. Anyway, I didn't use the lotion or baby powder, so maybe the insurance company can get the money back? Not that I'm so keen on helping out the insurance company, but then maybe our premiums would go down, or something like that.

Do the incidentals include the use of hospital gowns? Cause I brought my own, so can that be deducted too? The day I was discharged a volunteer came in and gave me a small plant; what portion of the 71K was that little schefflera?

Just the room and board alone was close to $25,000. I could have rented a room at a nice hotel in Philadelphia with that money. I sure didn't eat many meals (read: ONE that wasn't sippable, and there weren't too many of the sippable kind, come to think of it) so there should be a reduction in the "board" amount, too.

I guess I shouldn't be complaining too much, as I said earlier, our insurance company did pay for most of the bill, but I just wonder what kind of world it is where insurance companies will pay $71,000 for "incidentals" but won't approve more than one level of TDR (total disc replacement) when a doctor deems it necessary. As in essential. As in the opposite of "incidental."

Shout outs!

Now that I'm one month past my surgery, I'd like to give some shout outs to the hospital staff that made impressions on me during my stay.

A big shout out to Angela, the Physical Therapist on my floor. She insisted that I practice getting in and out of a car (they had half a fake one in the rehab room) even though my post-surgery instuctions say "absolutely no automobile travel until your follow up appointment." She also said I had to try steps. Again, the instructions warn against steps.

A shout out to my nurse the first day after my surgery. I still don't know her name (in my mind she is "Dumb Dora"), as she consistently refused to write it on the little whiteboard by my bed for that purpose. She never came to check on me that first morning, as if she had, she would have seen that I was laying (on my side, thankfully!) in my own puke. Instead this was discovered when Dr. Balderston and Theresa came in for rounds first thing. Someone must have gotten reamed a new one from Dr. B. and Theresa because as soon as they left there were about seven people in my room, including the Nurse Manager. Dumb Dora then stuck her face next to my ear and shouted, as though I was a deaf, mentally challenged 4-year-old that didn't speak English, "Do you want something for nausea?" I think I rolled my eyes and said "what do you think?" I had to really bite my tongue, as I'm sure you can imagine what I wanted to say.

A second well-deserved shout out to Dumb Dora, who, when I asked for something for pain after I had been taken off the IV Demerol, refused to read the second page of my chart where the previous nurse, Patrice, had noted that I was getting Darvon, not oral Demerol (which is ineffectual). It wasn't until I picked up the phone and started dialing Theresa that she miraculously summoned the energy to flip the page and find the most recent additions to my chart and get the correct pain meds.

A shout out to the Nurse Assistant (or whatever they are called) who was attending to my roommate the night of my surgery and who double dipped with her bare, ungloved, probably unwashed hand into my cup of ice chips.

A shout out to whoever the nurse was for my roommate who left her stuck on a (full) bed pan for 18 minutes (we timed it).

A shout out to the Physical Therapist who was on duty on Saturday and came right after I went through the horror of having the tube thrust up my nose and down into my stomach and then, ignoring my wishes to not get up right then (the tube was really, really uncomfortable plus I would have had to carry the cannister with the black, red and green slime in it around with us!), asked the nurse if it could be disconnected "for a few minutes" so I could walk around the floor with her and presumably practice getting into a car and going up and down steps.

A shout out to my nurse Barbara, who left the clear plastic container with the black, red and green slime in it hanging on the wall above my bed for three more days.

Yet another shout out to Dumb Dora, for standing over me with her arms folded across her chest not helping or offering any comfort whatsoever while I cried out in pain, unable to move myself from my bed over to the gurney that was waiting to take me to xray the day after surgery. Once I manoevered my way over without her help, she dashed back to her seat at the nurses station stating loudly to the other nurses, "She had her arm in the wrong position." Yes, that was it and it was all my fault, Dora.

And still another shout out to Dumb Dora for, when I asked for something for heartburn (my acid reflux was killing me as I had to lay flat to comfort my back), telling me that laying flat to comfort my back or propping myself up to relieve the heartburn was "a decision I would have to make." Again with her arms folded across her chest, like she was mad at me for having had heartburn.

A shout out to the entire nursing staff who ignored three calls from me for pain medication over a two hour period between a quarter to six and eight fifteen in the morning on Saturday. By the time someone came in (incidentally, NOT a member of the nursing staff, an NP with orthopedics who was doing weekend rounds) and summoned the nurse (and no, it wasn't Dumb Dora), I was in tears and incoherent with anger.

I'm really not a complainer but come on; some of this stuff is just beyond the pale. I do have some positive shout outs, unfortunately not very many. I'm researching an essay on the health careless situation in nursing, and wanted to get these out there first. Stay tuned for my take on the "nursing crisis."

Patients/Patience

Did you ever hear the old pun, "I wanted to be a doctor, but I didn't have any patience (patients)?"

I had just about given up on talking to anyone at Dr. B's office without exploding into an angry tirade, so I had Tyler call. Here I mentioned that it had been a week since I'd called right after the announcement came about the FDA approval and hadn't heard back. Just after that entry, I called again, this time asking to speak with someone in scheduling for Dr. Balderston intstead of his NP, (who really is handling all of this very poorly). I spoke to someone who we'll call "K" (no allusion to Kafka or Joseph K intended), who was very nice and understanding when I explained that the not calling patients back business was unacceptable. When I'd called the Thursday before, they said they would call back. Ok, so when someone, especially a doctor's office says that they will call you back, I sort of expected a call back within a few hours or at least by the next day. K explained that the reason no one called is because they were all waiting to meet with Dr. B. and his NP to decide who would be seen and in what order and that both Dr. B. and his NP had been and were still out on vacation and wouldn't even be back until the following Monday.

Well, OK! Why couldn't someone just have called and told me, and the other frantic patients, that? Do any of these "administrators" have any idea what it feels like to need an operation to be able to stand up straight and walk any distance and to be free of pain and then to have the doctor's office who is supposed to do the surgery NOT RETURN A CALL? It feels like you've fallen through the cracks, like maybe you need to start all over with another doctor after all this time, or like you are doomed to just get worse and worse till you are finally riding around in a wheelchair with really strong arms. I told K that she wasn't working for some five-star snooty New York restaurant that could have an attitude and not return calls if they didn't feel like it, this was my doctor. My doctor! To not have a return call from a doctor's office for 7 whole days is unconscionable. It's not like I call all the time and harrass them. K assured me that as soon as they all met and decided who would be getting appointments, they would be calling us all back.

OK.

A whole other week goes by and now I'm out of patience, thinking that I can't stand it, that I would be able to stand it if only someone would call me and tell me that I'd have to stand it another few months, another six months, another year, ok? But just freakin' call me back and tell me! I understand that they were probably swamped with calls, but as I said here, hire a freaking temp nurse! It's not like they weren't anticipating this kind of reaction from their patients. We're desparate, for crying out loud! We're all in pain, and in various states of disability, can anyone blame us for being impatient about when we might have surgery?

The end of this tale does have a sort of happy ending and here it is. When Tyler called on Thursday (a full two weeks after I called the first time: Shame on them!)K immediately said that Dr. B. wanted to see me and launched into a list of available appointments. When he asked what the delay was in calling back, she said that they'd just gotten the list together that morning. Whatever.

Ok, the windup is I go this coming Friday at 8AM. I don't know what he's going to tell me, but at least I'll get some face time and get some questions answered and even if he tells me it is going to be more of a wait, at least I'll be able to have patience.