The Administration of America’s Healthcare:Eyewitness Account of Insurance Bureaucracy

Insurance companies function as the gate keepers of our healthcare dollars which is a double edged sword. Yes, they should control the overboard spending that occurs when physicians order expensive procedures and tests to insure protection against malpractice litigation. (She screams Tort Reform, but that’s another blog story!) But the hoops that insurance companies insist that their clients (patients) have to jump through is just plain wrong!

Radiofrequency nerve ablation or RA is one of the newer procedures in the arsenal to treat chronic pain. Heat waves are used to destroy nerve fibers that conduct pain pathways, thus reducing the pain felt by the patient. The positive effects can last from 6 months to about a year, depending on the patient, nerve damage, and disease processes. I have had the procedure performed 3 times to date and I can attest that it does work well, although the journey there is tedious, frustrating, and painful.

Insurance companies do not arbitrarily invent rules and regulations for the premium paying masses to conform to. They have a medical director, board of directors, and nurse case managers who make the decisions and then enforce their edicts upon us with a simple statement, “Follow the guidelines, or the claim will not be paid.” And they would have you believe that their creativity for development of these insurance standards has a higher purpose; to insure that our healthcare dollars are spent in the most cost efficient manner while achieving the best medical outcome for the patient.

Really? Not a chance! As any patient can tell you, many of the guidelines make no sense at all. For those of us with chronic pain, radiofrequency ablation (RA) provides some short term relief from the day in and day out constant attack of pain. But to have the procedure, you have to endure facet nerve blocks as a diagnostic test. The test is painful and usually sends the patient to bed for several days. Two weeks later, the RA procedure can be performed and if you require another treatment on the opposite side of the spine or at another level, you must have the diagnostic test again. Get it? Repeat the sequence; more pain, bed, wait 2 weeks, RA treatment.

Then it gets worse. Once the effects of the RA treatment wane, insurance guidelines require a specific period of time before retreatment, regardless of the recommendations of the physician who is treating the patient. So the patient is allowed to regress back into a very painful condition. And once that guideline is achieved, the patient is horrified when they are informed that they must have the facet nerve block diagnostic test again before each treatment. Repeat the sequence; more pain, bed rest, wait 2 weeks, RA treatment. Does this insure that our healthcare dollars are spent in the most cost effective manner? Remind me how the insurance standards are set up to serve as a patient advocacy to achieve the best outcome. Not hardly! Waste of money, time, and more important, the well being of the patient!

As you talk to others who are trying to maneuver the healthcare maze, the stories will astound you. Here are a few examples:

• Pharmacology tiers which determine the medications you must take before receiving the prescribed medication.
• Certain medications are too expensive and are prohibited. (Yes, you can have them, but you pay the premium and you pay for the medication too. This one has happened to some of my friends with MS and cancer.)
• Length of inpatient stays are all determined by insurance guidelines regardless of your physician recommendations or the current condition of the inpatient.
• Patients who receive substandard treatment because their primary provider will not provide a referral to a specialist.
• Patients whose insurance maximum is exceeded due to a catastrophic illness and they are now left virtually uninsured.

You must learn to be your own patient advocate. Read your insurance guidelines. Know what your policy covers and what you are paying for in your premium. Learn to read an EOB, the explanation of benefits that is produced by your insurance company, when each claim is paid or denied. If you don’t understand, contact the human resources department of your employer, but don’t rely on your questions being answered by the HR director of your company. They are not insurance coverage specialists! Ask them to set up a meeting with the representative or agent from the insurance carrier. Many times this person can be your liaison between you and the insurance company and they can get problems resolved quicker than you can on your own. They can assist you in the appeal process and many times they know of a special compensation that can be made on behalf of a patient.

Along with your employer, your physician also has leverage with your insurance carrier to ensure a good outcome for you, the patient. They hire coding and appeal specialists who really do work as your advocate since you are both after the same thing; quality care and treatment for the patient and claim payment.

But even as I write this, healthcare as we now know it is in flux and the transformation of healthcare is leaning towards more regulations, increasing costs, and more demands upon medical staff to care for more patients. So, buyers beware or, in this case, patients beware!    

MRI's and X-Rays Tell a Story of their Own!






 



4 level involvement seen on MRI



This cervical x-ray and MRI was taken when I started to experience numbness along with chronic pain. I was only 28 years old when the evidence of spinal degenerative disease was already advancing. After careful consultation with several physicians, a decision was made to go ahead with my first cervical fusion. As the day of surgery approached, I decided that I would rather live with pain than go ahead with such a drastic surgical procedure and I cancelled the surgery. I continued with physical therapy to strengthen the muscles necessary to support the cervical column and everything seemed to be improving. In 1993 my condition took a serious turn. The numbness progressed down my left arm to the point where I started to lose function and the muscles began to atrophy, so against all my fears I went ahead with the surgery.




Titanium Plate with 6 screws post

I was placed in a denison brace for 3 months. You can only imagine how uncomfortable this torture device is! And my pain only increased after the surgery, followed by vertigo and disorientation! After suffering damage to the glossopharyngeal nerve, I had to learn how to swallow again. Everything ricocheted out of my mouth and the only good thing that came from this was that I lost some needed weight.



4 months in a denison brace



 

 





After suffering with increased pain for another couple of years, my surgeon determined that the fusion did not heal properly. To correct the fibrous union, I had a C3-C6 posterior fusion with bone grafting. That should have decreased my pain, but it increased again! But at least this time, I had a philadelphia collar instead of a denison!


 





Anterior C3-C6 Fusion with bone grafting and plating



10 to 15 years after a fusion, the level below the fusion begins to deteriorate. Why is this something that is never discussed at the time of surgery? You can't continue to operate and there is no such thing as a total spine replacement for those who suffer with spinal degenerative disease, so you find yourself regulated to a lifetime of chronic pain.

And just to make life more challenging, spinal degenerative disease does not confine itself to one portion of the spine. Before long, the thoracic and lumbar spine are involved which accounts for two more surgeries, loss of gainful employment, and disability. 

But there is always a light at the end of the tunnel. Just after the darkness of the night, comes the light of the morning. A new day, another chance, a day of restoration. As all those who suffer with chronic pain know, there is a point where you have to make a choice; to give up or to go on. And with God, all things are possible. Life is worth living. And yes, we can live with our chronic pain, holding onto the hope that tomorrow may bring a day without pain!

When Disability Becomes an Identity Thief

When your career comes to a sudden and abrupt end, the loss can be staggering. Suddenly I found myself unable to work, unable to contribute to the support of my family, and lost without my occupation. My co-workers were my friends, but they kept in touch with me for only a short time after my disability began. Our conversations went something like this:

Friend: “How are you doing?”

Me: “I am doing ok, but only by the grace of God. It’s hard.”

Friend: “Really? I wish I could stop working and do all the things I never have time to do.”

Me: “Well, it’s not really like that. First of all, if you’re ill or injured, you can’t do all the things that you want to do. It’s frustrating.”

Friend: “I’m sure it can be, but it must be like a vacation. You can travel whenever you want and if you’re not feeling well one day, you can just stay home. You can’t do that and work.”

Me: “It’s not a vacation. You don’t have an income. And if you’re too ill to work, why do you think you are well enough to travel?”

Friend: “Oh I didn’t mean it that way, I was just dreaming. You are so lucky. Take up a hobby or just kick back and relax.”

Me: “I don’t feel lucky. I miss work and I feel angry that this is happening to me. You know I’m not sure who I am without my job.”

Friend: “Gee, it was nice talking to you and I wish I had more time, but I have to work. We’ll keep in touch.”

And then they don’t call anymore and they act too busy when you call them. Everything that you know changes in the blink of an eye.

I was plagued by one question. Who am I? I had been a healthcare administrator for years and it had become part of my persona. As a professional working woman, I was comfortable making decisions, having authority, and I had excelled at my work, but who was I now? Disability had become my identity thief.

I had a very active lifestyle and suddenly I was being told to relax. With my increasing physical limitations, constant pain, and the loss of the ability to drive, I was home bound. I couldn’t use my arms for more than twenty minutes at a time without having severe pain. Simple tasks had become difficult. Cooking a meal, using a computer to answer e-mails, or playing piano became overwhelming. I couldn’t find a hobby that didn’t increase my chronic pain.

And you start to wonder, “How in the world am I supposed to enjoy living when I can’t do anything without pain? What in the world am I supposed to do besides give up? The loss of physical abilities along with the respect, achievements, and accomplishments from my career, left me feeling like I had nothing left. I began to feel that I was worthless, alone, and robbed of my former self.

I had always been a self reliant, independent woman, but now I was dependent on my husband. Irrational fear of being left alone and fear of the unknown future started to consume my thoughts. I slipped deeper into a depressive, angry state, where I either cried, or was sharp and abrasive. I clung to my husband’s side as if I was about to lose him at any moment. But whenever he tried to help me, I pushed him away. Why was God allowing this to happen to me? I was being stripped of every shred of my identity and without my career, I didn’t really know who I was anymore!

And then I started thinking about a man who once had it all and was at the peak of his career. He rose to the highest level, was admired by many, and everything in his career was perfect. Everyone he touched was made perfect. At thirty three years of age, his life drastically changed and he began to experience rejection, suffering, and torment like no one has ever known. He was abandoned by those who were his friends. He felt incredible pain as nails were driven into his hands and feet. But he knew who he was, he knew that his life was so much more than his career, and he knew that God had a glorious plan for him. Jesus was the Lamb of God who saved man from sin.

That’s when I finally stopped asking questions. I began to pray for God to fulfill His plan for my life; whatever that may be. Once I began reading the Bible, earnestly praying, and praising God, peace settled over me and I was comforted in knowing that God has a wonderful plan for me too. I am not my career. That was only a job. Chronic pain does not define who I am. Each new day is no longer a challenge, it is a new chance to see where God will take me.

Addiction to Pain Medication; Can that happen to me?

For those who suffer from intolerable chronic pain, medication becomes vital in the quest to control pain. And every true chronic pain sufferer knows the difference between medication that is used to obtain relief and abuse.

But the trap is easy to fall into. Chronic pain and depression go hand in hand. When you find yourself unable to perform simple tasks and enjoy the pleasures of life, depression creeps in, oozing its way past your ability to make rational decisions. As a pain patient, you will come to the crossroads where you start to ask the difficult questions.

Having a good relationship with your pain management specialist is vital to getting the answers to your questions. If you don’t have a doctor that you can talk to and who is willing to take the time to answer your questions, provide reassurance and guidance, leave and find another physician!

I am very fortunate and blessed to have found an excellent physician after navigating the chronic pain physician maze. His expertise, supervision, and care are essential in my personal rehabilitation and quest for recovery to the highest functional level. When I asked my physician these questions, he supplied me with honest and candid advice.

1. Will I become addicted to prescription medications if I take this pain medication over a long period of time?

 The answer is No! You will not develop an addiction if you take your medication as prescribed. You will have a dependence on the medication, but that is not an addiction. Dependence is when you require the medication to achieve pain relief. Addiction is when you constantly strive to increase your dosage to obtain euphoria from the drug itself. Unfortunately, when you take pain medication as prescribed, you will develop a tolerance that will require slowly increasing the dosage to obtain relief, but that is not abuse or addiction.

2. My pain is less today. Do I have to continue my medication even though I am not in pain?

That depends on the medication itself. Long acting medications do require that you take them as prescribed to achieve pain coverage while short acting preparations can be reduced as pain is reduced.

3. Should I take the medication just in case I have a recurrence of pain?

I struggle with this one the most! It is the “what if” mentality. What if my pain gets out of control or what if I get worse, etc, etc. The “what if” mentality leads to worry and fear. And chronic pain sufferers know that stress, worry, and fear lead directly to increased pain. Even with this knowledge, I find great difficulty coping with the “what if’s”. So, take your medication as prescribed and stop trying to second guess. Don’t take extra medication to satisfy the “what if” mentality.

4. I feel worse. Should I increase my medication?

Simple one. The answer is no! If you are still in pain or are having break through pain, talk to your physician. He will guide you, make the decision for you, and prescribe the appropriate medication.

5. I am feeling better. Should I decrease my medication?

Simple answer again. The answer is no! Talk to your physician. Don’t start decreasing your pain medication without the knowledge and consent of your physician. You might suddenly trigger an acute pain attack or withdrawal symptoms that you are unprepared to handle on your own. And of course, I would love to tell you that I have never done this on my own, but that would be a lie. After working in healthcare nursing and administration for over 30 years, I have a tendency to try diagnosing and treating on my own and it almost always ends with a crisis. You would think that after 28 years of chronic pain that I would know better! Like many of you, I sometimes just hate to swallow another pill, but I strongly recommend that you talk to your physician before changing dosages on your own!

6. Is it alright to drink just a little bit of alcohol with my pain medication?

Yes and no. An occasional sip or small glass of wine or alcohol doesn’t seem to hurt as long as you know your medication and know that the effects are increased from alcohol, but there is a word of extreme caution here. Pain can grossly affect your judgment!

I never and I mean never touch alcohol any more, not even wine or beer. As I said, I have endured many years of chronic pain and I have many experiences, good and very bad. During a particularly lousy time in my life, when my marriage was failing and divorce loomed on the horizon, I had slipped into depression without anyone noticing. Then I started to drink socially.

At first, it was fun and it lifted my sour moods considerably and then I realized that drinking with pain medication worked, and it was downhill from there. The improved pain control and relief felt like a blessing. For the first time in a very long time, I was not coping with a degree of pain. We all know the pain scale, 0 to 10 with 10 being the worst ever. At that time, my daily life consisted of a steady 5, but when I drank, my number went down to a 2 or 3.

So what do you think happened? Yes you guessed it. I started drinking more to see if I could improve and I rationalized that it was acceptable to drink a sufficient amount of alcohol to reduce my number to a 1 or 0. And I did. And I liked it very much! But before long, I started drinking more, and taking more pain medication. I didn’t want to live with or experience chronic pain anymore and I thought that I had found the perfect solution!

This is how alcohol and drug abuse begins, slowly at first, it gathers steam, and then you lose control. The road back is hard for everyone. Many addictions begin from a legit case of pain, but when a chronic pain patient falls down this bunny hole, recovery is extremely difficult. A smoker doesn’t need cigarettes to breathe and live, just like an alcoholic doesn’t need booze to survive, although the transition to be smoke and alcohol free requires a herculean effort. A food addict still needs food for survival. You can’t completely stop eating. And just like that, a chronic pain patient requires pain medication to subsist. Without it, life becomes just a horrible existence without any enjoyment.

So it is exceedingly important for the pain patient to follow the recommendations of their physician to avoid the trappings of narcotic abuse. And even though fear abounds each day from a new article in the papers, online, and on the air waves regarding prescription drug abuse with increasing statistics on deaths from overdoses, the pain patient must navigate through this quagmire.

       He gives power to the weak, And to those who have no might He increases strength.

Isaiah 40:29

Even the strongest people get tired, but God’s power and strength never diminish. He is never too tired or too busy to help and listen. His strength is our source of strength. When we feel all of life crushing us and we cannot go another step, remember that you can call upon God to renew your strength. Hold your head up high, proudly step over the stigma and hushed accusation that you too are an abuser. With God’s help, you will survive, and once again enjoy your life!