Case 114: Patient Spared Toe Amputation and HMO Spared Hospital Costs and Pays Nothing

At age 65, patient LG was referred by our hospital referral service for control of his diabetes and for swollen feet. His sugars had been in the 200's for several years in spite of the diet and oral agents his physician had prescribed. His ankles had been numb for two years. He had been smoking 1.5 packs of cigarettes since age 20. His initial diagnoses included his diabetes mellitus, peripheral neuropathy, peripheral arteriosclerosis obliterans and mild chronic obstructive pulmonary disease. He was instructed in insulin administration and proper diet. His glycohemoglobin dropped from 8.5% on December 16th, 1996 to 5.9% on April 18th, 1997. His diabetes remains well controlled.

His foot problem began with a trip to Florida where he did a lot of walking. He returned January 24th, 1997 with a swollen infected left 2nd toe (1st photograph); he had a modest hammer toe deformity and an ulcer in the callus on the end of the toe. Pressure areas were also seen on the dorsum of the 3rd, 4th and 5th toes. A probe was entered into his ulcer hitting bone and a culture was taken; a heavy growth of Staphylococcus aureus was later reported.

His second toe was swollen and ulcerated.

A probe could enter the ulcer to the bone.

His care was complicated by the fact that he had recently joined a HMO-Medicare-65 program in the belief that all of their advertisements were correct and that all of his care would be covered. He had no palpable distal pulses and was advised that he had to go to an approved HMO vascular testing site (not an easy task for a sick man with a sore foot). He was also advised that he likely had osteomyelitis of the distal phalanx of the 2nd toe and should start therapy immediately. "Standard" therapy was offered: hospitalization, intravenous antibiotics and bedrest with possible vascular reconstruction surgery and amputation of his toe. He was advised that a better option would be our outpatient boot program: an injection of gentamicin immediately into the end of the toe to ensure a significant amount of antibiotic reached the infected area and Mini-Boot therapy to disseminate the injected antibiotic around the toe, to reduce swelling and to improve the arterial circulation in his lower leg. He was also advised that his HMO would likely approve the therapy to avoid hospitalization and then not pay us for the therapy claiming it was not covered or necessary. Hence, he was advised that he had to sign a form saying that he would be responsible for costs if he was indeed denied. He preferred our boot option and was given an oral antibiotic to intercept any septic emboli that might develop with the inception of his booting. His wife went in search of his primary physician who provided the necessary referral sheets. A request for pre-certification was faxed to the HMO. During the days of review by the HMO, the patient chose to follow advice and obtain therapy; he was concerned properly for the fate of his toe. Over seven days, he received daily a cleansing foot soak, an injection of antibiotic into the end of his toe and Mini-Boot therapy. His toe improved.

On February 2nd, he learned that his care was to be denied. Perhaps, the sight of the advanced lesions of other patients in the boot clinic had increased his anxiety. He NEEDED care. If it was not to be allowed at our facility, he would find one where it was allowed. He went to a newly opened wound healing clinic. He was referred to a Philadelphia Wound Healing Center. There the x-rays and vascular tests we were not given permission to perform were accomplished. He was advised that he indeed did have an osteomyelitis of his toe and that he should be admitted to the hospital for an amputation of the toe. No one prescribed any new therapy; his antibiotic treatments during the course of this illness was limited to that injected in his toe and prescribed orally to block septic emboli. He noted that his toe was improved and saw no emergency. On March 5th, however, he returned to the boot clinic for consultation regarding his toe; the amputation was scheduled for March 6th. He was advised that except for the scab on the end of his toe, the toe appeared normal and that his x-ray would return to normal slowly over the course of several months much like the x-ray of a toe fracture might. He canceled the surgery.

On March 5th, the 2nd toe appeared normal except for a scab.

The swelling of the toe had receded and the skin color was essentially normal.

He returned March 19th for a diabetes visit. The scab had fallen off and the toe appeared normal. His HMO had been spared the cost of an unnecessary hospitalization. He does not know if the wound healing clinics were ever reimbursed for their services. He appropriately lodged a grievance with the HMO. which was provided with the facts and photographs of his case on March 17th. As of June 10th the HMO has not responded. .

On March 19th, the 2nd toes of both feet were very similar in color and size.

Only a small dimple remained where the scab had fallen off.

Comments: Patients do well to inquire of their doctors as to the honesty and performance of various health care organizations before they join. Patients belonging to the HMO described in this case will be treated as second class persons. Doctors and clinics must pay their bills also. Failure of the HMO to pay its reasonable obligations adds additional costs on the rest of us. This case was an easy one for us. We saw it early and commenced effective therapy immediately.