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."

Nil per os

I ended up with just one ProDisc and the other two bad discs fused. I'm very disappointed in this result, I really, really, wanted the three discs, but aside from this, I'm doing pretty darn good.

The first few days after surgery weren't so good. I was out of it and in a lot of pain, and then they gave me morphine even though I told them not to. The morning after the procedure I woke up to see my doctor standing next to me with, like, a seven thousand dollar suit a big smile and told him if he didn't want puke on his pants, he needed to step back. The whole side of the bed and me were soaked with puke. It was in my hair, everywhere. I heard Theresa say, "oh, why'd they give her morphine? She gets sick on that." Why indeed? I told the anesthesiologist and anyone would would listen that anasthesia and morhine make me vomit. How is it they don't share this information? Or remember it?

The days after that and leading up to yesterday were pretty much run of the mill post-op days: me out of it and getting ignored by nurses. I sometimes wonder why people with absolutely no compassion or aptitude for working with people go into health care.

Today was the first day I felt coherent in any way. I have some kind of condition or complication called "ileus" which occured as a result of my internal orgrans being moved all around during the surgery. The remedy for this is, of course, to pass gas. I've never had so many people so interested in my farts. Every doctor, nurse, intern and nurse's aide that's come by here since the surgery has asked (sometimes more than once) if I'm "passing any gas?"
They say that average person passes gas around 15-20 times a day. Talk about taking something for granted. I'm up to maybe four times a day and each time, it's a real event. I've been up walking around the floor here, getting my own ice chips, etc. in an attempt to get my sluggish bowels moving, but it's unfortunately a very slow progress.

Yesterday I had the singular indignity of having a tube inserted in my nose, down my throat and into my stomach to try to "decompress" my abdomen. So on top of everything else, I had to sit here watching blackish blood and greenish slime being pumped out of my guts through my nose. I actually asked , no demanded that this be done because my stomach was so distended my skin felt like it was going to snap, this is a very weird feeling. The nurses were saying they could have bounced a quarter off my belly. I was dosed up with drugs, fell asleep and pulled the tube out. Thank god they said they didn't want to put it back in. The canister with the yucky guts stuff in it is still hanging on a hook on the wall. I've had three sets of xrays, called "obstruction series" looking for what was in there. I overheard one of the doctors say it was a dilated loop, so apparently it is just several giant gas bubbles.

It's been seven days now that I haven't eaten. I'm allowed to chew/suck on ice chips but that's it. I've been fantasizing about what I want to eat when I 'm allowed, and it isn't even the elaborate steak or lobster dinner that most people might crave, I'm thinking about everyday little things like Triscuits, some raisins, maybe a handful of almonds, and hot cup of strong tea. Oh, yeah, pretty darn good.

Health Careless II

Got a call from someone named Melissa, Melinda, Melanie, whatever, some minion of Maureen (yes, this tactless clerk has minions). She was calling to tell me that the claim that was submitted to Aetna for the three level replacement was ... wait for it ... denied. She started to tell me that if I wanted, I could appeal. That was when I stopped her.

"Listen, I think you are missing some information," I tell her. I explain that we already knew about the insurance company denying the claim, as we'd been notified last week when we got our online statement from Aetna, but we didn't sweat it because Dr. B. had just told us that he was resubmitting two new configurations to them that had a good chance of being approved (since we'd be paying out of pocket for some of it). I was more than a little concerned because

a) When we saw Dr. B. on the 25th, he said they were going to get to work on it "right away." A week later is "right away?"

and

b) Maureen and her posse are the ones that are supposed to be up on all the insurance company stuff! That's what they do, that's their job. How come they didn't even know that there had been a change to what was being submitted? It didn't sound to me like they were working in the same office I'd been in the previous Friday. It also didn't sound like any of the new configurations we'd talked about with Dr. B. had even made it to the insurance company yet.

MM (Maureen's Minion) shuffled some papers around and said she didn't have my papers in front of her (then why was she calling me? To recite the same gloomy crap she says to every one else?)but that she would "look around" and get back to me.

I hung up and called Theresa, Dr. B's NP. Normally I wouldn't call her, since she hates talking to patients, but figured I would get her voice mail and so wouldn't have to have any actual interaction with her and of course I was right. I told her that I'd been to see Dr. Balderston last Friday (like she hadn't seen me hobbling down the hall with my cane and looked right through me, yeah) and that we'd discussed resubmitting two new configurations of the surgery to the insurance company, and why did Maureen and her minions not know of it since they were the ones that were supposed to get working on it "right away" last week?

I also told her that she was to tell that whole office, Maureen and all of her minions, to lose my phone number, that the last thing I needed was these women calling with all this negative news on top of everything else. Just call me when you've got it together, ok? Why do I have to be reminded every step of the way that I'm being shafted by the insurance company? I gave her Tyler's number to call back as I'd just as soon not have her get back to me, adding that she didn't seem to anxious to talk to patients either.

About a half an hour later, Tyler gets a call from a very apologetic Maureen, saying that she had just gotten the paperwork (explaining the various steps in between my appointment and her and her minions) and that it would be submitted tomorrow. Since we are coming up on the December 6th date that Dr. B. had penciled in for my surgery, the absolute last date we could get approval and still make that date is this Friday, the 10th.

So now I'm in another set of knots waiting for Friday, wondering if they'll hear back from the insurance company in time so the surgery won't have to be delayed again, and if it does have to be rescheduled, let's hope, for all our sakes, that someone besides Maureen or her minions calls to let me know.

The Queen of Denial

Maureen should not be allowed to talk to patients.

As I said here, according to Maureen, my clain with Aetna will be denied/rejected/refused/disallowed/declined. Then once I get the letter saying a resounding and predicted-numerous-times-by Maureen "NO," I have to decide how I want to appeal. Of course, as you may have read in the last post, this news threw me into a panic. I don’t know the first thing about appealing anything to an insurance company. Do I get an attorney? I’ve seen this kind of thing in movies and on Dateline, no one wins appeals against insurance companies!

So I asked Tyler to call and see what he could find out; he always has better luck getting info. For some reason, none of the staff in Dr. B’s office seem neither to want nor be even slightly equipped to actually communicate with patients. He spoke with the ever elusive Theresa, Dr. B's NP, who tried to immediately transfer him back to Maureen. Once he was allowed to get a sentence out, here’s what she told him about the whole process:

Every insurance company is rejecting any claim for more than one level of ADR. Once they reject mine, Dr. B has attorneys that will handle the appeal and on top of that, he sits on a board that advises insurance companies about the need for surgery, so he's confident that he'll be able to get two levels. In addition, he has several different permutations of the procedure that I need that will get appropriate payment for the hospital (such as charging a bit more for one disc to help offset the cost of the second, etc.) so that I will be assured of getting the two discs I definitely need. If worse comes to worst, Tyler said that we will pay out of pocket for the second disc (buy those t-shirts, people!). It’s all very confusing, not made any less so by the machinations we have to go through to get someone who will actually take the time to look at the big picture and then explain it to us. I guess it is really too much to ask to have someone be a little encouraging and optimistic when speaking with patients who are terrified and in pain, unlike Maureen, the humorless Queen of Denial.