More Prodisc drama

More on the Prodisc lawsuits, and Dr. B is quoted. For some reason, this doesn't bother me; I figure if they've got some financial investment in seeing that a surgery is successful, then the chances are better that it will be. There's probably all kinds of things wrong with thinking like that, but there you have it.

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.

A Straight Line

Supposedly the shortest distance between two points is a straight line. Unfortunately, the shortest distance between me and the surgery I need seems to be a more zig-zagged trajectory, involving several different versions of what is to be done to me for the benefit of the insurance company, along with a liberal sprinkling of our cash.

After all the waiting to see Dr. Balderston, after all the anxious days and weeks wondering what was happening to my body, fretting over the insurance company delays and frustrated with not hearing back from anyone in his office, when he walked in and started off with his usual, “talk to me,” I could barely formulate a sentence. I was too terrified of what the answers would be to ask the questions I had. I’d been sick, literally sick to my stomach, for a few nights in a row, worried about the visit, and the outcome.

We looked at the xrays from September, and he showed me where the vertebrae had slid to the side (see picture below, click to see it larger), something that happened just in the last six months or so.



I also saw how the other disc had collapsed completely, leaving the vertebrae to grind together, bone on bone. Just below that was the disc that collapsed unevenly, causing me to pitch forward.

Click to see larger:



When I asked what the possible timeline was, he grimaced, saying he didn’t have a crystal ball, but then started to say something about how they had had “some luck” with some insurance companies by just submitting for the fusion (he had planned to fuse one of my vertebrae, the L3-4 along with putting in the two ProDiscs at L5-S1 and possibly L4-5 if he can pry it apart sufficiently) and then submitting that they were also doing an ADR and would the insurance company pay for the additional operating room time, hospitalization, anesthetic, etc., if the patient paid out of pocket for the surgeon’s fee for the installation of the disc and the cost of the device itself. I realize that he can't come straight out and say these things, but the hints went right over my head. Thank goodness Tyler was there and picked up on it. Once he told Dr. B that we would be willing to do that, Dr. B said they would start working on it right away, adding that it would still be another “few weeks at least.” He also said the insurance company personnel were “evil,” that clerks with little or no medical training were making medical decisions and trying to dictate what kind of surgery I and other patients in my situation would have, but that he would make sure that I got the configuration that I need, even if we have to pay for it (Somehow that sounds wrong, but oh well …).

So now they will resubmit to the insurance company for the fusion and one disc we will pay for the rest. It’s very scary and only partly because of the money we’ll be spending that the insurance company should shelling out. What also concerns me is that he doesn’t think we should wait for the insurance company to fool around, but rather that we should just go ahead and do something now, before it’s too late to do anything. This of course only adds to the anxiety that I already have about every step that I take putting me closer and closer to inoperability and never standing up straight again. He’s penciled me in again for December 6th and hopefully this time the line will go straight from here to there.

Money stuff

I'm disabled! It's official!

Right. Normally, I wouldn't celebrate this kind of news, but when it means getting some money, at this point, I'm all for it! I love Mr. Tingle in all his Dickensian/Kafkan splendor, as I believe that he, along with my doctor writing a letter stating that I was indeed non-functioning, was a large part of my being approved.

Just this past weekend, with the realization that even if Aetna pays for everything, they won't pay for everything, as our plan only covers 90% of in-patient/surgical care, I've finally gotten off my ass and set up an online shop to make some money and help out with day-to-day stuff like paying the dog walker, since I can't walk Tony as much as he needs, and to partially subsidize the cabs I have to take to go even a few blocks.

Money, and the lack thereof, has always been a sore subject for me, so to ask people to buy my stuff to help me out is hard, but I hope soon I can celebrate getting some money for something besides being disabled (hint hint).