The new documentary by Michael Moore called SICKO has launched nationwide heralding the cry of health care reform due to the inadequacies of the health care system. In “Medical Disasters and How to Avoid Them” Dr. Pierce Scranton, an Orthopedic Surgeon, arms us with practical tips on how to take charge of our own experiences while at a hospital and he teaches us how to protect ourselves and prevent any travesty that could occur. In a series of six articles, HealthWorld Online and Dr. Pierce Scranton, will provide actual case by case, behind the scenes scenarios, along with tips on how NOT to have these experiences happen to you. In the fifth installment you will the importance of knowing how to avoid pitfalls when visiting the emergency room.
Case 6 – Z.B..’s Denial of Care by HMO
Z. B. was a 47 year old auto mechanic who had taken a very hard fall onto his left hip twenty years earlier. Gradually over the decades he developed progressive deep anterior hip pain. He began to limp, and he had difficulty sleeping at night due to the pain. His HMO family doctor prescribed an anti-inflammatory medication and told him he had “a little bursitis.” However the pain and the limp became worse, and on his own Z.B. started using his grandfather’s cane to help take pressure off the hip. He went back to the HMO family doctor and requested an X-ray of the hip. This showed severe arthritic destruction of the hip. Z.B asked if there was a different anti-inflammatory that he could use, but the doctor said that the HMO got a discounted contract to only use one, and besides, he smiled, “They’re all the same.”
Z. B. developed a bleeding ulcer due to the anti-inflammatory medication, but the HMO did not offer alternative medication. So he was referred to an orthopedist. The orthopedist explained to Z.B that his hip was “totally destroyed.” When Z.B. mentioned that he was an auto mechanic, the orthopedist told him that surgery would be experimental in his young age range, and besides, the low cost total hip procedure that HMO offered was a small, discounted 28 mm femoral head in a conventional hip replacement, and squatting or kneeling to work on a car would dislocate the hip. Due to his young age and occupation, the HMO denied hip surgery as “unproven and experimental.”
Z.B. started using narcotic pain medication in an effort to keep his job, and deal with the pain. He still had difficulty sleeping at night, and he took to having several shots of alcohol to try to drug himself to sleep. However his wife saw the changes in his mood, and she began to research total hip replacement on the internet. She discovered that the procedure the HMO offered was out of date, and that “Resurfacing, Ceramic-on-ceramic, Metal-on-metal, and 32mm Oxinium Ceramic-on-Poly total hips” were all available, and had been for many years. Through physician-finders she had Z.B. get two different second opinions. Then they appealed to the HMO. The HMO still refused to authorize the surgery, but through their questioning during the hearing and the body language of the orthopedist they could tell that these were valid options. They went ahead and spent their savings and chose one of the outside surgeons to perform the surgery. It was successful, and Z.B retained his job and got off all medication and alcohol. They sued the HMO for “breach of contract,” and during the discovery it was noted that the surgeons were bonused on the number of patients they saw that they did not operate on. The case was settled before trial and the records sealed by the judge.
How to avoid denial of care.
1. Be engaged. Get clear information on your diagnosis and what treatment options are. Ask for a letter to be sent to you spelling out all the options, even though many of those options may not be recommended. To double check, look up the diagnosis on the Internet using Google, HealthyNet.com, Web MD.com, and other sources to explore treatment options. Write down exactly what the diagnosis is as you understand it, and all the treatment options the doctor has explained to you, and other options you may have discovered on your own.
2. Get a second opinion. Request copies of your X-rays and records. See another physician for a second opinion, up front, letting that physician know that you are requesting a second opinion. Do NOT waste that physician’s time letting him know all the information you know from the internet. You can make a list of treatment options you’re aware of, and let the doctor see it and ask for comments. However, the second opinion doctor does not need to learn about all your findings on the Internet. To parade this is an insult and waste of that doctor’s time.
3. In cases of denial of coverage or service, when it is very clear that other alternatives of care are available and that they are not experimental, then you must obtain the services of a good lawyer.
Remember, it’s your health and well-being that’s on the line. Be engaged in the process, and stay healthy!