the cost conundrum

“I’ve been an AK for 23 years and can only wish that my prosthetic allowed me to be as active as I was prior to losing my limb. It is nowhere near as good as the real deal, and I have [a] $100,000 leg. No kidding. That’s what was billed to my insurance company.”

Cheryl, less is more reader, commenting on “the disconnect“

“[A]mputees [ ]would be a lot better served with better products for far lower prices. … [The prosthetic hands I happily use] cost $400 to $700 bucks[.] 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 [not] guilty of [ ] paying for shamelessly overpriced gadgets[.]“

Wolf, less is more reader, commenting on “the disconnect“

While the term “prosthetic costs” means different things to the different players in the U.S. health care system, few would describe these devices as “cheap.” Insurance companies pay thousands of dollars even for low-end prostheses, while technologically advanced ones cost tens of thousands, with some breaking the $100,000 barrier.

Why do prosthetics cost so much? It’s a fair question.

*   *   *

the component-part manufacturer

Companies like the one I work for invent (or buy from others), fabricate, and sell a wide range of components, ranging from prosthetic hips, knees and feet for people with lower extremity limb loss to prosthetic fingers, hands and arms for upper extremity amputees. They also make liners, adaptors and pyramids that prosthetists use to assemble the finished prosthesis.

If you ask a component-part manufacturer about the cost of its devices, you’ll get a detailed lesson in the product development and manufacturing process. What starts as a concept “drawn” into a computer eventually makes its way to the marketplace, typically over the course of 18-24 months, and in the case of more complex technologies – think myoelectric, microprocessor, and motor-powered devices – two to three times longer than that.

The manufacturer then has to take into account the costs of manufacturing and assembling these products once they’re market-ready. You have the expense of the raw materials used in the device; the costs of purchasing certain sub-elements – particularly in the case of more sophisticated technology – from other manufacturers; and the expense of operating the factory where a team of people and costly machines make the item.

Next, you have the development of marketing and educational materials, as well as the fixed costs of a sales force that provides both information and support to providers actually fitting the device. Finally, you have the costs associated with maintaining and supporting the product post-launch. This provides a high-level snapshot overview of the expenses associated with a product, and it doesn’t even take into account a myriad of other expenses I’ve left out for the sake of simplicity (e.g., legal/regulatory expenses, etc.)

While you may say this model supports bloat and expense, no viable alternative to it has come to the fore. The Open Prosthetics Project – an open source approach to prosthetic solutions – has close to 600 members, but hasn’t disrupted the traditional approach yet.

the prosthetist

Prosthetists buy most of their prosthetic parts from component-parts manufacturers. In addition, they have to purchase plastics and other materials to custom-fabricate the prosthetic socket that’s fit to the patient’s residual limb.

In addition, prosthetists do not get paid on a “per visit” basis. Payors only reimburse them for delivering a device, an amount that implicitly includes both the time the prosthetist spent fabricating and assembling the prosthesis, and the time associated with all necessary follow-up treatment and training.

So when you talk about prosthetic costs with a prosthetist, he’ll typically take into account the following: (1) all of the costs associated with buying components, plus (2) all of the costs of the raw materials that he crafts into a socket, plus (3) the cost of his time to make the prosthesis, plus (4) the estimated future cost of seeing you multiple times after delivery to both adjust the prosthesis and, if necessary, train you to use it effectively.

the payor

All payors, whether governmental or private, think of prosthetic costs as the amounts billed to them by prosthetists. And payors – especially private insurance companies – have increasingly shifted health care costs towards consumers over the last 8-10 years.

While the stated goal of cost shifting is to encourage patients to make economically-intelligent health care decisions, most data suggest that the primary effect is to discourage patients from seeking any health care at all, which may lead to higher health costs when they finally do seek treatment. Secondarily, cost shifting results in lower expenditures and higher profitability for payors, while purportedly helping employers keep insurance premiums from spiraling out of control.

the patient

That leaves us with the people who need prosthetic care and who increasingly shoulder a higher share of the prosthetic cost burden. We want the prosthesis that’s most comfortable and that gives us the greatest possible mobility. Over the last decade, our wants have often led us to more complex (read: expensive) prosthetic solutions. We wear a prosthesis that brings us closer to a four-limbed individual’s functional level, but it comes at a higher cost, both in terms of raw dollars and the amounts that we’re asked to spend in the form of copays and deductibles.

*   *   *

“[Y]ou act as if prosthetic prices were ‘as is.’”

Wolf, less is more reader, commenting on “the disconnect“

The question of whether the economics of this system make sense or treat people with limb loss fairly doesn’t have an easy answer. Like it or not, in the U.S. right now prosthetic prices are ‘as is.’ While alternatives may theoretically exist, implementing them might come with other costs, such as discouraging innovation or encouraging the use of less expensive and less functional materials.

I’m employed by a component-parts manufacturer today. I worked for and co-owned a prosthetic facility before that. I’ve been an amputee since 1996. And I represented payors in the early part of my professional life.

The only thing I know for sure is that there are no easy answers to the cost conundrum.

ok

“What advice would you give the survivors who lost limbs?” the reporter asks me. “Jones Beach,” I think silently. Not the right answer, but it’s the starting point.

*   *   *

The 12 months after my accident flash by in what feels like a few weeks: in-patient rehab, prosthesis, learn to walk, learn to run, finish 10k race, return to work, catch up on what I missed … adjust. Suddenly, 365 days have gone by, and I now have a new anniversary to memorialize. One year to race from whole to broken to reconstructed. I have a leg. Then I don’t. Then I do. Metal, plastic and carbon graphite screwed together so I can walk in a straight line. Linear.

I sit in my windowless office staring at my computer monitor on the anniversary. I need do something significant. The day feels like it should be significant.

I pull my London Fog trench coat off of the hanger on the back of my door, grab my hat, and walk out of the glass towers popping up out of the flatness that’s Uniondale. No lunch today.

I climb into my gold Nissan Altima, purchased with the proceeds from my Accidental Death and Dismemberment insurance policy. Getting hit by a car allows me to get another car, one with an automatic transmission. I slide the right side of my body into the seat, my foot finding the brake easily. My left leg stays behind until I lift my thigh off the seat, manually bending the prosthetic knee so that it clears the door. I swing it into the car, manually positioning the foot.

I drive. The Meadowbrook Parkway escorts me south towards the Atlantic Ocean.

For some reason I think that Jones Beach on a biting winter afternoon will honor this historic day. Why I think this makes little sense. I hate the beach. I’ve lived on Long Island since 9th grade and gone to the beach less than 5 times. But today it seems right, and suddenly the boardwalk lies under my feet. I lean into the wind, feeling the wood flex underneath my right foot, and sit down on a weathered bench, the wood gray and cracked.

The surf pounds a sandy football field away. Even with the wind, I can hear it. I wrap the trench coat around me and try to convince myself that the winter sun will warm me on this cloudless, bright blue sky day.

Waves explode against the sand, booming, distant. I can’t answer the questions I’m asking myself as I shiver on the bench. “Why am I still here?” Nothing. “Why is this day important?” Empty. “Shouldn’t there be some deeper meaning to this?” Waves boom. Seagulls shriek. Lots of noise around me, but that’s it.

I drive back to work.

*   *   *

It’s 2003 and I’m in my office. A law enforcement official sits across from me. She’s got a death grip on the kleenex in her hand and tears run down her face. White sneaker on one foot, her swollen limb still wrapped in bandages. Stopped vehicle on the side of the road violently pushed into motion when struck from behind, pinning her between car and guard rail. One leg made it over the guard rail as she tried to escape. The other didn’t.

She tells me it’s “tough.” She doesn’t understand why she cries. She doesn’t know when these feelings will end.

The tears keep coming. I stare. She stops and looks at me. Despairing.

I start talking. I’ve not said these words before, this way.

“Look, there’s no right or wrong way to feel about this. Everyone who loses a limb feels something, but there’s no script. It’s ok to cry, it’s ok to be angry, it’s ok to be depressed. I can’t tell you the first thing about when those feelings will come or how long they’ll last. For me, everything happened really quickly. Maybe a few days and then all I cared about was my rehab, and I blocked everything else out. But that doesn’t mean my way is the same as yours, or that because my way took less time it was better.

The only thing I can tell you with certainty, and the one thing I hope you trust and believe, is that there will come a day when you wake up and putting on your prosthesis isn’t a reminder of pain, of loss, of a life you once had. It’s just a piece of you, of who you are.”

I pause. She’s looking down into her lap, but the tears have slowed.

“I can’t tell you when that day will come. I hope it’s next week, but it could be next month, or even next year. But always remember that it will happen. And you’ll know it when it does. And everything will be fine. It’ll be ok.”

She sniffles and nods.

A month later, she cries again. She has taken her first step on a prosthesis. And the smile makes her tears shine.

*   *   *

I don’t tell the full story to the reporter, but I repeat what I said to the officer. “Everything will be ok.” Two weeks out from the Boston Marathon and the press wants soundbites. Mine isn’t the catchiest, but I’m pretty sure it’s true.

my guide: obsession

The upstairs lunchroom succumbed to my invasion without a struggle. I told my employees I needed to escape the phone perched on the corner of my desk and its winking green and red lights. But when I swallowed up the only table in the room, burying it under 323 index cards, that’s when they probably started questioning if one of their company’s founders had snapped.

*   *   *

I’m obsessive. When Green Day first released American Idiot, nothing else played on my iPod for four months. I’ve watched Moulin Rouge at least 50 times.  I spent so many hours playing Tetris in college that colored, rotating shapes floated across my field of vision while Professor Knopp droned on about Shakespeare.

Indulging this trait drives those around me to exasperation. My wife can’t fend off the sonic bludgeoning of “Jesus of Suburbia” or screening number 92 of Ewan McGregor’s forays into Paris’s seamy 18th century underbelly unless she fires off a magazine of negative critical artillery that forces me back into my foxhole. It’s the only way she can survive.

But I can also use my obsessiveness for good on occasion.

After I lost my leg, my pathological focus on understanding the biomechanics of human gait allowed me to walk again more quickly than I thought possible. A 10-minute presentation tends to go smoothly after I’ve practiced it for 3-5 hours. And when it comes to insurance appeals, my belief that I could (and had to) find a better way to present my patient’s case yielded excellent results when I still owned my prosthetic facility.

Those obsessive traits continue to serve me. Yesterday, I slogged through a workers compensation insurer’s labyrinthine denial. Its analysis boils down to this: why should an amputee need a prosthetic foot that has a moving ankle?

Now, if I go to that insurer’s office tomorrow and ask the doctor who penned the “not medically necessary” letter whether he believes ankles are medically necessary, I bet he answers yes. If I inquire whether he prefers life with a fused ankle or an articulating one, I think he chooses the latter. And if I pump him full of truth serum, I think he admits that his “coverage position” is nothing more than a pretext for cost containment.

Using my legal training and decade-plus of reimbursement experience, I have coined a technical term that describes this kind of payor analysis: stupid. And I obsess about stupidity.

This specific kind of stupidity led me to take over the second-floor lunchroom in early 2006 and release a waterfall of 3” x 5” index cards across the pale faux-wood table. Each card contained a single element of an argument supporting my patient’s need for a microprocessor-controlled knee.

At the time, I had an appeal win rate well in excess of 90%. But I believed with a zealot’s ardor that I could somehow reshape the 9/10′ths appeal and pick up another 7%, 5%, or even 2%. I knew that yesterday’s good enough would decay into tomorrow’s failure. Those forces drove me to inundate a table with index cards in 2006. And they forced me to buy Storycraft, a fascinating primer on how to write narrative nonfiction, a little over a month ago.

*   *   *

I sit at a bar in Glen Ellyn, Illinois, writing this. I’ll wake up in the morning and take the elevator to the basement meeting room. I’ll stand in front of prosthetists and their billing staff, separated by tables containing metal water pitchers and brightly-colored cylinders of plastic-wrapped candy no one will eat. They will wait for me to say something that will help free them from the claims tar pit sucking their businesses into oblivion.

I bought Storycraft because I thought it might contain a brilliant insight I could use in that presentation, which focuses in significant part on effective storytelling. But my talk doesn’t need a brilliant insight about narrative. It already works, just like my 9/10′ths appeal.

In fact, I only ventured into the book’s core after I had already assembled the various talking points and drills that now comprise my four-hour talk. But as I slipped deeper into the text this weekend, I realized I didn’t need the book for my presentation. I needed it for this.

I’ve always joked – the best jokes being built on truth – that the weekly format I’ve chosen for less is more works for me because it plays to my lack of discipline (read: laziness). While I’ve always thought I had the potential to write exceptionally well, my screeds in these e-pages always feel only partially cooked to me, examples of not-quite-realized potential. Storycraft reveals why.

Its author, Jack Hart, thinks about writing the same way I think about appeals and presentations. Years of experience combined with a systematic approach to the art result in a riveting “how to” do what I try (and usually fail) to do every week. But like the member of my audience who agrees with my presentation and then goes back to his practice and implements none of it, I now know that if I want to write better, more interesting stories, I’ll have to treat less is more a bit more like “Jesus of Suburbia” and a bit less like a secondary hobby.

While this means I’ll need to work hard in the upcoming days, weeks, and months, I find the prospect exhilarating. Instead of noodling around with wordplay and sometimes humorous (sometimes not) one-liners, I now have the chance to refocus on themes, structure, and arc. For the first time, I see a map that can lead me someplace new and better.

I can’t promise that my writing will improve significantly in future posts. But you have my word that I’ll obsess about it. And that’s a healthy obsession.