#10: coaching my sons’ baseball teams

Starting with Max and continuing with Jackson, I’ve now coached youth baseball from tee ball through sixth grade through most of the last decade. When I started with them back in kindergarten, we had to spend the first three practices of the season reviewing what a prosthesis is and why I’m wearing one or else no one would take batting practice. Today, those same kids take it for granted, much as I do. They don’t have an amputee coaching them; they have a coach who’s an amputee. Cool transformation.

#9: waterskiing

When I was a kid, I waterskied every summer at my grandfather’s cottage on a lake in Maine. I don’t have lots of sepia-toned, awash-in-nostalgia memories from my childhood, but the month we spent in Harrison every July-August qualifies.

Almost 20 years after last doing it, I tried waterskiing again with some friends in Massachusetts. After a few failed attempts, I successfully got up and even cut across the wake a few times.

I couldn’t come close to replicating what I did with two legs, but just feeling that pull out of the water and hearing the hiss of spray underneath me brought me back to those summers where all I did was pester my grandfather to take me out for another run.

#8: refusing to get a handicapped car tag

At least once a month when I can’t find parking, I mutter under my breath, “That handicapped tag would come in handy right about now.” But I don’t really mean it.

In my mind, it’s a badge establishing the user’s limitations. (What do you think when you get stuck in traffic behind a slow-moving car with a handicapped license plate?) My kids stopped asking long ago why I don’t claim this parking advantage. They know better.

#7: completing the CAF 10-miler

I’ve run farther. I’ve run faster. But I’ve never finished anything like the 10-mile course that the Challenged Athletes’ Foundation inflicts upon its participants in La Jolla, California.

The highlight, if you can call it that, is the ascent from the ocean to the clouds. As you wonder about the availability of supplemental oxygen, altitude sickness, and getting hit by an airplane, this Mother of All Hills just keeps going. And going. And going.

#6: learning how to redefine success

It took me 15 years as an amputee to figure out that the measure of success when I run isn’t the time on my stopwatch, but the checkmark on the calendar confirming that I ran at all. Coming from a guy so competitive that I tried to cheat my grandmother out of a win in the card game War when I was 5, this qualifies as a revelation.

I’d whip myself into some semblance of shape every third year after losing my leg, only to scrap the undertaking after competing in yet another race where a 57-year-old endomorph blew past me in the final quarter-mile. And then, finally, I let it go. I ran because I wanted to stay healthy.

And I ran farther and faster than I ever had since losing my leg.

5: the rock wall ascent

I’d watched other parents do it for years at kids’ birthday parties. But finally, goaded by Jackson, I let the staff at the indoor rock climbing place throw a harness on me.

My technique, I’m sure, stunk. My arms shook spastically less than halfway up. But I made it. As I looked down at my wife and kids before belaying back down the 30 foot sheer face I had conquered, I could feel the adrenaline and pride surging through me.

4: 13.3 on marathon day

A few years ago, I took off on a run the same day as the New York City Marathon. It was one of those perfect November days – crisp and cool, with no clouds in the sky.

I meant to do 6 miles. I felt great, so kept on going for another 3. Still felt good and decided to try to get to 12. Got to 12, felt like garbage, but convinced myself that I’d never run 13+ again if I didn’t gut through it right then. The last 1.5 felt like a lesson in how to break apart my body, piece by piece.

But on the same day that thousands in New York finished 26 miles, I clocked in at 13.3. Great day.

3: starting less is more

I hadn’t done any “fun” writing in years. But as I returned from the Amputee Coalition’s 2010 National Conference in California, years of disparate ideas that had floated unused around my brain suddenly coalesced into the concept that became this blog.

I wrote the first two posts on the early morning plane ride back to New York, and have, for the most part, continued finding something to write about every week since then. The fact that even one person finds my ravings worth reading still amazes me, but I do love it.

2: climbing a real mountain

When my friend and fellow employee, Linda, told me I had to climb a mountain in Scottsdale, I stupidly accepted. I had visions of a long, boring walk up a somewhat steep hill.

I got a long, somewhat terrifying climb up a trail covered in shifting rocks, with steep cliffs on either side that reminded me how a misstep could lead Very Bad Things. My legs were rubber by the time I reached the summit, and then we had to come back down, which I learned added a new degree of terror to the venture. I felt like a car with no brakes on the descent.

Wouldn’t trade it for anything.

1: rehabbing from my accident

You can’t capture in words how otherworldly it is to wake up in a bed missing part of your body and then trying to figure out how you’re going to get through the rest of your life as an amputee. I had never met an amputee before my accident. I knew nothing – nothing – about prosthetics. I had never even used crutches or had stitches before my accident. Ever.

I ultimately discovered, upon returning to work and my “normal” life, that everything I really thought was important – work, career, professional success – wasn’t, and everything that I gave lip service to – family and friends – mattered most.

Ironically, once I came to that realization, my career took off and I became more successful professionally. But, with a few bumps along the way, I’ve managed to keep ahold of that perspective, and I wouldn’t trade it for anything.

conclusion

Whether you’re an amputee or not, take the time to make this list for yourself. It has a way of putting things in perspective.

“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.

What if I told you that last week’s post and this week’s podcast cover the same general subject? What if I told you that the overlap notwithstanding, this week’s podcast is a “must-listen?”

What if I told you that The Amputee Mommy raises some thorny issues about access to prosthetic care during our talk? What if I told you that “thorny” is a euphemism for “thought-provoking and important?”

What if I told you that we could have talked for 90 minutes about this topic? What if I told you that because we respect your time, you instead get just over 23 minutes of condensed brilliance? What if I told you that 22:45 seconds of that condensed brilliance occurs because of The Amputee Mommy?

Check out this week’s Amp’d, which tackles the fallout from the Boston Marathon bombings.

*   *   *

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.

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.

I’m trying to wrap my head around this.

One minute, you’re standing watching the end of a race, celebrating a family member’s dedication and accomplishment. The next, you’re in the middle of a blast zone.

I normally write less is more posts on Monday night. Last evening, wading through news reports of the dead and at least 25-30 people having 1 or more limbs blown off – and I suspect the number of amputees will climb in the combing days and weeks, perhaps dramatically – any thoughts I had of writing something for today went by the wayside.

Keep the victims in your thoughts.

I can’t think of anything else to say.

You’d probably be happy. So listen to this week’s Amp’d, where the Amputee Mommy and I discuss the world of prosthetic covers for prosthetics. It’s the closest you’ll ever get to me talking about fashion publicly. Enjoy.

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.

When I lost my leg in 1996, everything old became new again. Getting out of bed in the middle of the night presented new challenges. Getting dressed in the morning suddenly required thought and planning. And walking, one of the most basic and simplest human activities, now demanded intense attention.

Every prosthetist in the United States should be able to relate to that experience. Because in the last 18 months, everything old and reliable has become new and undependable.

color by numbers

When I owned my own prosthetic facility, the process of providing a patient a prosthesis presented few challenges. I could file a claim with Medicare and other payors and predict the likely outcome with 90% certainty. I knew which claims would get paid and which would get denied. I could even predict the likely basis for denial in most instances.

I left the patient care side of prosthetics in late 2006 to work for a prosthetic component manufacturer, but the basic model for filing claims remained the same. The prosthetist examined the patient and recorded his findings. Those findings got incorporated into a letter of medical necessity that the prosthetist sent to the patient’s doctor. That letter detailed the patient’s condition and her need for a new socket, knee, foot, liner, or a new prosthesis entirely. The doctor would write the requested prescription and the prosthetist would then file the claim.

So long as you established the medical necessity of the prescribed device, Medicare would pay you. Private payors were nearly as predictable.

Medicare rarely audited claims. Private payers did so even less. Until everything changed.

the shift

In August 2011, the Office of the Inspector General issued a report on lower limb prosthetics. OIG’s concluded that Medicare erroneously paid $97M in prosthetic claims, or roughly 16% of the total annual Medicare spend on these devices. (Many in the O&P industry dispute  OIG’s conclusions. However, what no one can contest is that this report shaped the federal government’s perception of prosthetic claims.)

Almost simultaneously, each of the four contractors hired by Medicare to process claims in different regions of the United States issued “Dear Physician” letters. These letters required doctors to record specific patient information in their medical records. They included a list of desired clinical findings stretching across 14 bullet points. The contractors noted that these clinical criteria were by no means exhaustive.

Next, Medicare’s auditing contractors swung into action. These Recovery Auditors started reviewing old claims, sometimes looking back as far as three years while applying the standards set forth in the Dear Physician letters retroactively. Since the vast majority of claims filed before the Dear Physician letters lacked that level of documentation – especially in the prescribing physician’s medical records – the RA’s ruled that they didn’t comply with Medicare’s requirements and demanded immediate repayment from prosthetists.

On top of retroactive audits, the same contractors that had issued the Dear Physician letters began launching “widespread prepayment claim reviews.” Focusing on the documentation supporting particular types of claims – generally those that involved the delivery of higher-cost prosthetics – these reviews occur after the prosthetist delivers the prosthesis but before Medicare pays the claim.

By the end of 2012, the limited evidence available suggested that audits had become the rule, not the exception for O&P businesses. An American Orthotic and Prosthetic Association survey of its membership last fall revealed that more than 75% of the prosthetic facilities in the United States were fighting at least one audit.

In a little more than 12 months, filing a Medicare claim had gone from color by numbers to the equivalent of trying to replicate a Salvador Dali painting, stroke for stroke … for every claim.

what’s old is new again

In my current role, I get to speak to prosthetists around the United States about the state of the prosthetics profession. I present my vision of how to navigate the claims process successfully. It’s one of my favorite parts of the job. I’ve delivered countless talks at national conferences, at local events, and at seminars over the past 24 months.

The tenor and content (and title) of these talks have changed dramatically since I began delivering them in February 2011. The ideas I presented that seemed like overkill then receive a very different reception now.

Prosthetists express dismay, anger, sadness and frustration in equal parts when talking about how a process they understood and depended on changed so quickly. As I watch and listen to them describe these sudden and profound shifts, I can’t help but think about the hundreds of new amputee consultations I participated in when I still owned my facility.

I would shake my head sympathetically as people described how their life had taken this inexplicable turn, how everything they knew and understood had become alien. I would reassure them. I told them, based upon my own personal experience and conviction, that someday – I couldn’t tell them when, but someday – they would wake up and the act of putting on a prosthesis and walking with it would be a natural part of their lives.

It’s hard to overstate how much the claims process has changed in just over a year. I can shake my head sympathetically as I talk with these small business owners. I can offer my thoughts about how to successfully operate a company in this environment. And I can tell them that as they improve their internal systems and shore up their claim processes, what they see as inefficient and mechanical today will become second nature tomorrow.

It used to be that patients and prosthetists shared an experience that revolved around the patients’ rehabilitation. Now they also share the experience of having to relearn everything they took for granted.

The prosthetists who figure out how to rehabilitate their businesses quickest will have a decided advantage over those who can’t. The difference is that you can measure a patients’ success by how many steps they take or how dextrous they are with their prosthetic hands and fingers. We’ll be measuring a prosthetist’s success by how many are still operating in 2014.

In the pantheon of Things Likely Not to End Well, delivering a 3 hour and 30 minute presentation on no sleep the morning after returning to the U.S. from Iceland ranks high on the list. Further complicating things, I couldn’t get the projector to display my slides. Add in a sophisticated audience that has put patient care on hold for half a day and you begin to get a feel for what I confronted last Friday morning.

*   *   *

Speaking in front of people doesn’t scare me. It really never has. Maybe it started in grade school when one of my teachers, suffering from laryngitis, asked me to read long sections of a book to the class, a duty he normally reserved for himself. The fact that he chose me rather than any of the other students led me to believe that I must have preternatural reading and speaking abilities. (File, as always, under “Delusion.”)

When I played on high school sports teams, I was the kid who stood up at the season-ending awards ceremony to say a few words thanking our coaches. When I attended law school I discovered that despite my strong tendencies towards introversion, I enjoyed standing up in front of a fake jury and arguing the merits of an imaginary case. And as I grew older and had the opportunity to speak in different venues – whether the opening ceremonies at the Amputee Coalition’s national conference, or at other events as a panelist or solo presenter – the act of standing in front of large rooms full of people and spouting off became increasingly enjoyable.

It went beyond just wanting to do it. I needed to be that guy. I watched other people present and unconsciously thought about what I could have done differently or, more often than not, how I believed I could do it better. It’s not an exaggeration to say that every time I watch someone else present I get physically agitated, my mind blasting along, telling me how I could convey that information more effectively that the person standing in front of me.

Just this past weekend the trait reared its ugly head at my son’s middle-school play. One of his classmates had the kind of role that you kill for – that one scene that allows you to steal the show. He nailed it the first night. But on Saturday, he ran into problems.

His microphone somehow picked up interference on its frequency. (Think air traffic control in Spinal Tap.) No matter how much the guy at the sound board tried to control for it, jazz music inexplicably piped through the speakers on his mic. Mind you, it wasn’t so loud that you couldn’t hear him, but it was distinct enough to thoroughly distract everyone from what he was saying and doing.

As I watched the sound guy flip knobs and shrug helplessly, and saw the audience staring desperately around the theater looking for someone to fix the snafu, I thought about what I would do if I were on stage. And I quickly decided that during the character’s extended and imaginary death scene, he could simply reference the fact that in addition to seeing the white light, he could hear the angels playing music, though he didn’t know they liked jazz. While not the funniest line ever thought up on the spot, under those specific circumstances, I’m convinced it’s all the audience would have talked about had he pulled it off. That’s how compulsive I am about this stuff.

In any event, as I sat on the plane last week while flying over Greenland, the fact that I was still fine-tuning my presentation – as opposed to practicing it for the 100th time – sent tremors of terror into the reptilian parts of my brain that would have (hopefully) saved me from death millions of years ago.

*   *   *

When I consider the potential return on investment, I don’t know that it makes a whole lot of sense for me to continue to try to improve my public speaking skills. The chances at this stage of my career that anything I do is going to dramatically move the needle aren’t particularly high. If I did nothing but repeat the same patterns and habits that have gotten me to whatever level of expertise I currently possess, I’d probably still get decent feedback from audiences.

But I forge onward, my latest Kindle purchase a book on effective story telling that, it turns out, features multiple quotes from an old high school classmate and successful author. And as I took a break yesterday from trying to finalize the presentation that I started two weeks ago, continued on Icelandair last Thursday night, and that I have to deliver later this week, it hit me.

The things that end up meaning the most to me are the ones I do despite the uncertainty, whether it’s climbing a mountain in Arizona without first understanding the enormity of the task, using a chainsaw without hacking off another of my remaining limbs, or meditating regularly and hearing the dialogue in my own head. Or, for that matter, rehabilitating from the unexpected loss of a body part.

Similarly, scrapping a successful presentation that I’ve delivered for more than two years in exchange for entirely new content and a more interactive – read, “less controlled by me” – gets my pulse racing. That’s not necessarily the best place to be when you have to deliver that presentation to a room full of people in less than 24 hours. But then again, maybe it is.

*   *   *

I dragged my unshaven, jet-lagged self in front of the small audience last Friday. Bereft of a functioning projector, I placed my computer in the middle of the conference-room table so everyone could see my slides. I started talking knowing that I hadn’t had the chance to fully integrate several teaching examples into the final section. I hadn’t had the chance to do even one dry-run of the content before walking into the room.

It wasn’t perfect. Certain aspects went well, while others failed. When I got to the unfinished portion, I sat down at the table with my audience and explained what I hoped to achieve. Instead of “presenting,” I walked them through how I planned to deliver the content in the future. (I had scheduled this event explicitly as a “beta test” of my new presentation, so there was a tacit understanding that I’d need to work out kinks and finalize certain aspects while reworking others.)

I learned a lot by being “unprepared.” The comfort zone can cripple you.