the disconnect


the disconnect 04.23.13

We love the story of modern prosthetic technology. It usually involves people facing enormous physical and emotional challenges overcoming the odds, each their own little Rocky Balboa. The Rocky script feels even better a week after the Boston Marathon bombings. With one perpetrator in custody and the other dead, reporters now turn their attention to the survivors’ future, a story already foretold as equal parts sacrifice, heroism, and hope.

Most people reading these articles will conclude that modern prosthetic components restore amputees to something very nearly approximating their pre-amputation state. But the reality is more complex. And that story doesn’t get told.

*   *   *

Yesterday I received an email containing a denial from a major integrated health system/insurance company. The denial includes the payor’s statement that it only pays for a “standard” prosthesis.

Many insurance companies take similar policy positions. They exclude “deluxe” prostheses, or cover only “traditional” items.

These euphemisms for “less expensive” leave people unfamiliar with prosthetics with the impression that the most high-tech, advanced technologies provide unnecessary benefits to the people who use them. After all, you don’t need powered windows in your car – they’re just nice to have. In fact, insurers often compare prostheses to cars, asking, “Why do we need to pay for a Ferrari when the Ford also gets us from point A to point B?”

But the well-publicized advances in modern prosthetics aren’t the equivalent of power windows, iPhone-Bluetooth integration, or $1,500 rims, despite the exclusionary language in insurance policies implying that they are. And this disconnect masks the underlying reality of why amputees often have so much trouble getting access to appropriate prosthetic technology.

*   *   *

Kirsten and I ate lunch together at Clearwater Florida during a break in the conference. She shared with me her efforts to educate Canadian governmental officials about what modern prosthetic components can and cannot do.

“First,” Kirsten explains, “I make everyone in the room an amputee. I ask them as they’re sitting in their chairs to imagine that their left leg ends just above the knee.” She smiles brightly and continues. “Next I ask them to stand up without using their hands or arms. And they quickly realize that this is a real problem.” She makes them (try to) do this several times, the audience suddenly struggling with an activity it never thinks about normally.

And then Kirsten pops the question: “Do you think that your standard prosthesis should help lift you out of a chair?” The government officials, likely pondering the reality that if Kirsten doesn’t end this exercise they’ll never be able to make it out of the building, murmur their assent: they need a prosthesis that helps them transition from sitting to standing.

Then Kirsten informs them she can’t provide them this prosthesis. Not because she refuses to provide it, but because it doesn’t yet exist.* The most advanced prosthetic components ever created don’t provide this “standard” human function.

*   *   *

While the gap between prosthetic limbs and human anatomy has closed considerably over the last 15 years, pretending it’s not there ignores reality. If you depict the distance between a microprocessor-controlled titanium joint and a biological one as a flight from Boston to L.A., prosthetics haven’t yet made it to Milwaukee.

Consider the fact that every prosthetic knee available today moves only in one plane. The closest equivalent for an able-bodied person consists of wearing a knee brace restricting you from doing anything other than bending and straightening your leg. Can you sit in a chair and swing a foot underneath you from left to right, like the pendulum of a mantle-top clock? If yes, you have basic anatomical motion surpassing even the most sophisticated prosthetic knees in the world. And if you can walk upstairs, one foot over the other, you have capabilities that only two prosthetic knees – both introduced in the last 12-18 months – provide amputees.

Similarly, what if you had to walk with a fused ankle for the rest of your life, starting today? For the vast majority of above and below-knee amputees, that’s their “normal,” as motor-controlled and powered ankle-foot systems have only become available in the last 6 years. Yet, the most fundamental benefit provided by the human ankle – the ability to plantarflex and dorsiflex the foot – remains a “deluxe” or “non-standard” item in the eyes of many insurance companies.

*   *   *

This doesn’t mean that amputees can’t live healthy, active lives. Successful amputees do just as much or more than their able-bodied peers, albeit with some workarounds.

But insurance companies continue to label prosthetic components non-standard or deluxe, despite the fact that they’re still pale imitations of the real thing. And that leads to my final question: would it be better if insurance companies just came out and said, “We don’t pay for prosthetic devices that cost more than $__ because they’re too expensive?”

My conclusion, as I now read it, veers dangerously close to “Insurance companies do things that make me angry.” This lacks the deep meaning I sought to find when I began this post. I suppose in that way, it resembles Rocky: emotionally resonant, but not profound.

*Since Kirsten’s talk with those governmental officials, one prosthetic knee for above-knee amputees has entered the marketplace that can help lift users out of a chair.

8 thoughts on “the disconnect

  1. As I read your profound post, I admittedly find myself crying. I’ve been an A.K. for 23 years, and can only wish that my prosthetic allowed me to be as active as I was prior to loosing my limb. It is nowhere near as good as the real deal, and I have $100,000 leg. No kidding. That’s what was billed to my insurance company. No, it’s not made of gold and precious stones, but I do have a microprocessor knee and an “ok” foot that I can adjust for different heal heights and lock in place. 17 years ago, I had to pay out of pocket $25,000, for a new prosthetic. People don’t realize that one prosthetic not only doesn’t even come close to plain ol’ simple walking of a real leg, but if you want to swim, you need another leg, if you want to run, you need another leg, if you want to ride a bicicle, you need another leg, if you want to do anything other than walk from your couch to your bedroom, you need another leg AND alllllll of the components that go with it ie knees/feet/nuts/bolts/pylons/pyramids/rotators/sockets/pins/liners/etc. Insurance barely pays for one leg, and as you’ve pointed out, they only begrudgingly pay for only “basic” parts…none of that “fancy” Ferrari kinda stuff. It’s awful!!! This typical 4-limbed person doesn’t have a clue. And I beg to differ that prosthetics have come so far as to allow some amputees to do the same, if not more, than the able-bodied group, as you suggested up above. If that’s true, it would only apply to less than 1% of the amputee population. You’re talking the crem de la crem athletes. This is not the norm. I can’t imagine these top successful amputees come home from a hard days’ work and just chill out. I bet they take their limbs off and attend to their battered skin.

    I’m frustrated because the parts for my expensive nowhere-near-as-good-as-the-real-deal are not being covered by insurance anymore. The same foot that I have used for probably 17 years, is no longer covered because it was deemed “medically unnecessary”. Are you KIDDING ME????

    In concluding my very frustrated rant, I concur with your statement “Insurance companies do things that make me angry!”

    • Cheryl:

      Thanks for sharing your experience.

      I hear you re. amputees doing more than able-bodied individuals. My thinking process when I wrote that was as follows: (1) many able-bodied Americans live sedentary, unhealthy lifestyles; (2) some amputees live comparatively active, healthy lifestyles; (3) therefore, there are amputees who do more than their able-bodied peers. That doesn’t mean they’re high-end athletes. It just means that maybe the amputee walks 7,000 steps a day while the able-bodied person walks 2,500.

      But your point is well taken.

      Thanks so much for reading and taking the time to reply!

  2. A not unimportant aspect in that debate however is that you act as if prosthetic prices were “as is”. If national insurances were to develop their own prostheses and sell them for a minimal manufacturing cost, soliciting technical contributions from industries where they are often available at low cost if one negotiates well, then the price debate would not be one. Currently, we have – for example – Otto Bock where the vast majority of employees (from my experience here, hand/s on) must be quite arrogant marketing specialists that have absolutely no idea how to deal with a technically proficient amputee that just trouble shooted their faulty produce and tells them what all is wrong with the product. Given that as reality, one cannot but wonder why their chairman Max Nader runs the company seemingly mainly to finance his costly carbon yacht hobby – a the expense of daily trouble of amputees who would be a lot better served with better products for far lower prices. There is a real reason why I like and support Becker hands that are fare more functional than the current Otto Bock Michelangelo hand – the Becker hands are really built by people with a heart, they cost 400 to 700 bucks, last a long time, and offer adaptive grips. That concept has certainly not been understood by manufacturers and as long as that is not the case I see no reason why insurances are guilty of not paying for shamelessly overpriced gadgets that really do not hold up to tasks such as what I put my terminal devices through. So from reading the above I cannot but conclude that you must be very partial to the prosthetic industry.

    • Wolf:

      Your last point first: as I note in the “about” section of less is more, I work for a prosthetic component manufacturer. So there’s little doubt I see the world at least in part through that lens. Not a lot I can do about that – it’s part of my life.

      As for your first point that I “act as if prosthetic prices were “as is,” I’m not sure I could write this particular post any other way. I’m addressing how things actually are in the U.S. reimbursement world today.

      Your alternative proposal – insurance companies developing their own prosthetic devices and controlling costs as a result – is an interesting concept, but it’s purely theoretical at this point in the U.S. Doesn’t mean that it’s not worth discussing, but it wasn’t the intended subject of this particular post.

      Thanks!

  3. Pingback: the cost conundrum | less is more

  4. Hi Dave,

    I was wondering where you hear about all the new products that come out on the market. And which products are you specifically referencing that assist a user in standing from a chair or that can walk upstairs? I’ve tried searching for these devices, but I always seem to end up in the wrong places.

    Thanks,
    Jeff

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