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.
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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.
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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.
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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.
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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.